Home Insurance Quote


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*Not required - but helpful in determining an accurate quote.
E-Mail Address:
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Residence Information:
Address of Residence:
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Amount of coverage desired:
 ,000
Deductible:
Size of residence: Sq. Ft.
Year residence was built:
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Basement:
Roof:
Check items that are a part of this residence:
Dead Bolts Covered Patio/Deck Smoke Detectors
Wood Stove Uncovered Patio/Deck Fire Extinguisher
Tennis Court Central Alarm System Swimming Pool

Claims/Losses: (3 most recent claims/losses)
Date
(mm/yy)
Amount
Paid
Description of Claim
1.
2.
3.
 

Insurance Carrier Information:

Are you currently insured:
If yes, who is your carrier?
How long have you been with your current carrier?
Expiration date:
(mm/dd/yyyy)
 

Other Information:

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Oronoque Shopping Plaza 7365 Main Street Stratford, CT 06614 Tel: 203-380-0453
Fax: 203-380-0683
shildneck@snet.net