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General Information
First Name: Last Name:
Current Address:
City: State: AKK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AA AE AP AS FM GU MH MP PR PW VI ZIP:
Email: Phone No: Fax No:
Rent or Own Home? Please Select.... Rent Own Other Years at Address:
Previous Address (If less than 3 yrs):
Current Insurance: YesNo Provider:
Coverage Start Date: End Date:
Occupant Information
Applicant
Full Name: Date of Birth:
Co-Applicant
Dogs
Breeds: Bite History:
Home Information
Year Built: Square Footage: Number of Stories:
Type of Construction: Please Select... Manufactured Log Wood Framed Other If other:
Type of Roof: Please Select... Comp Metal Shake Other If other:
Type of Wiring: Please Select... Circuit Breaker Box Fuse Panel Knob & Tube Other If other:
Type of Plumbing: Please Select... Copper PVC Other If other:
Type of Heating: Please Select... Forced Air (Gas) Forced Air (Electric) Electric Baseboard Other If other:
Type of Foundation: Please Select... Basement Crawlspace Slab Other If other:
Security System: Please Select... Central Local Police Department None Other If other:
Garage Type: Please Select... Attached Detached None Other Number of Parking Spaces:
Type of Fireplace: Please Select... Fireplace (Traditional) Fireplace (Gas) Wood stove None Other Number of Fireplaces:
Distance to Fire Station (Miles): Distance to Fire Hydrant (Feet):
Swimming Pool: Yes No Trampoline: Yes No
Current Coverage
If no current coverage, skip ahead to last section.
Dwelling: Coverage Amount:
Liability: Coverage Amount:
Medical: Coverage Amount:
Deductible: Coverage Amount:
Earthquake: Yes No
Scheduled Items: Coverage Amount:
Please Contact Me Via
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Hours: Monday - Friday, 9am - 5pm9am - 5pmpm
info@gelfandinsurance.com
Vancouver Office 9013 NE Highway 99 Suite A Vancouver, WA 98665 (360) 882-0619 Fax: (360) 883-2204 vancouver@gelfandinsurance.com
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