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Fill out the form below, and one of our agents will get back to you within 48 business hours.


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    General Information   

First Name:                                Last Name: 

Current Address: 

City:                      State:                      ZIP: 

Email:     Phone No:  Fax No:     

Rent or Own Home?                              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   

Full Name:               Date of Birth: 

    Dogs   

Breeds:     Bite History: 


    Home Information   


Year Built:            Square Footage:           Number of Stories: 

Type of Construction:                           If other

Type of Roof:                                  If other:        

Type of Wiring:                            If other: 

Type of Plumbing:                             If other: 

Type of Heating:                         If other: 

Type of Foundation:                          If other: 

Security System:                          If other: 

Garage Type:                         Number of Parking Spaces:        

Type of Fireplace:                   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   

Telephone           Email            Fax             Mail


Gelfand Insurance Group, IncInc

Hours: Monday - Friday, 9am - 5pm9am - 5pmpm

info@gelfandinsurance.com

West Linn Office

1975 SW 8th Avenue

West Linn, OR. 97068
(503) 650-3727
Fax: (503) 650-3828
westlinn@gelfandinsurance.com
Scappoose Office

33480 SW Chinook Plaza

Scappoose, OR 97054
(503) 543-0994
Fax: (503) 543-0975
scappoose@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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