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R. TAYLOR INSURANCE
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Name
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First
Last
Phone Number
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Marital Status
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Single
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Email
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Gender
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Date of Birth
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Mailing Address
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Line 1
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Property Address (if different from mailing address)
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Line 1
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City
State
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New Purchase?
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Yes
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Current Insurance Carrier
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Closing Date
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Desired Personal Liability Limit
*
$300,000
$500,000
$1,000,000
Type of Siding
*
Vinyl
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Wood
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Type of Heat
*
Natural Gas
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Foundation
*
Slab
Crawl Space
Unfinished Basement
Finished Basement
Pool
*
Yes- Below ground
Yes- Above ground
No
Fireplace
*
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No
Wood Burner
*
Yes- Inside
Yes- Outside
No
Pond
*
Yes
No
Trampoline
*
Yes
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Occupied by
*
Owner
Tenant
Vacant
Zipline
*
Yes
No
Farming Acreage
*
Yes
No
Business conducted on premise
*
Yes
No
Year of roof update
*
Do you own a dog? If yes, what is the breed?
*
Additional Scheduled Items
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Other Structures on Property
*
Detached garages, sheds, barns, utility buildings, animal enclosures, etc
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