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Currently Insured
Yes
No
Who is your current insurer?
AAA Insurance Co.
Allstate
American Family
Country Financial
Farmers
Geico
Liberty Mutual
Nationwide
Mercury
Met life
Progressive
State Farm
Travelers
Safe co The
Hartford
USA
Other
Not Currently Insured
Do you own this property?
Yes
No
Property Type
Single Family
Multi Family
Duplex
Townhome
Mobile Home
Condominium
What type of property is this?
Primary Residence
Seasonal Residence
Vacation Property
Rental Property
Number of stories?
1
2
3
4 or More
Number of bedrooms?
1
2
3
4
5 or More
Number of bathrooms?
1
2
3
4
5 or More
Type of roof?
Asphalt Shingle
Wood Shingle
Tile Shingle
Metal Roof
Not Sure/Other
How old is your property?
1-10 years
11-20 years
21-50 years
Over 50 years
What is the square footage?
500 or less
501-1000
1001-1500
1501-2000
2001-2500
2501-3000
3001-3500
3501-4000
4001-4500
4501-5000
5001 or more
How much is the value of your home?
$100,000 or less
$100,000 - $200,000
$200,000 - $300,000
$300,000 - $400,000
$400,000 - $500,000
$500,000 or more
What is your gender?
Male
Female
Non-Binary
Are you married?
Yes
No
What is your credit score?
Excellent
Good
Fair
Poor
Education Level
Less than High School
High School Diploma
College Degree
Some or No High School
Employment Status
Employed
Unemployed
First Name
Last Name
Address
State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
City
What is your zip code?
What is your date of birth?
Email
Phone Number
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