•
PERSONAL INFORMATION
First Name:
Last Name:
Address:
City:
State:
Zip Code:
Benefits Plus Client?
Yes
No
Benefits Plus Number:
Employer:
Home Phone:
(
) -
Work Phone:
(
) -
Ext. #:
Fax:
(
) -
Email Address:
Social Security #:
•
PROPERTY INFORMATION
Square Footage:
Dwelling Value:
Contents:
Pool?
Yes
No
Wind & Hail Coverage?
Yes
No
•
GENERAL INFORMATION
Central Alarm?
Yes
No
Installed By:
Hurricane Shutters?
Yes
No
Installed By:
Central Fire?
Yes
No
Flood Insurance?
Yes
No
Prior Coverage?
Yes
No
Liability Limits:
$100,000
$300,000
•
BUILDING INFORMATION
Year of Construction:
Construction Type:
Plumbing Updated?
Yes
No
Year Updated:
Electrical Updated?
Yes
No
Year Updated:
Roof Replacement?
Yes
No
List All Previous Claims, if any:
Proposed Effective Date:
Referred By:
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For more Information, please call:
R.V. Howard & Associates, Inc.
8487 S. US 1 Port St. Lucie, FL 34952
Tel.: (772) 343-9878
Fax: (772) 343-9884
Email:
PersonalLines@rvhoward.com
