Robert C Benner Insurance, LLC.

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Policy Holder
Contact Name*:
Date of Birth*:
Email*:
Phone Number:
Property Location
Address:
City:
State:
Zip:
County:
Current Insurance Information
Company Name:
Annual Premium:
Expiration Date:
Deductible Desired:
Amount of Liability:
County:
Earthquake Coverage: Yes
No
Have you filed for bankruptcy in the past 7 years?: Yes
No
Dwelling Information
Estimated Replacement Cost:
Square Footage:
Year Constructed:
How Many Floors: 1 Story
1.5 Story
2 Story
Bi-Level
Tri-Level
Other
Type of Construction: Wood
Stucco
Masonry
Brick Veneer
Aluminum Siding
Other
Other Features (check all that apply): Dead Bolts
Smoke Detectors
Fire Extinguisher
Central Station Fire Alarm
Central Station Burglar Alarm
Home is Within 5 Miles of a Fire Station
Home is Within 1000 Feet of a Fire Hydrant
Swimming Pool
Trampoline
Home is Within City Limits
County:
Claims - Last 3 Years
Claim 1 - Amount Paid:
Claim 1 - Claim Type:
Claim 1 - Description:
Claim 2 - Amount Paid:
Claim 2 - Claim Type:
Claim 2 - Description:
Claim 3 - Amount Paid:
Claim 3 - Claim Type:
Claim 3 - Description:
Personal Property - Estimated Values
Jewelry & Watches:
Furs:
Silver:
Firearms:
Stamp & Coin Collection:
Fine Arts and Breakable Items:
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