Hatfield Insurance Agency Inc

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Homeowners Quote Questionnaire


Name: *
Current Address: *
City: *
State: *
Zip: *
New Address: (if different) 
New City: (if different)
New State: (if different)
New Zip: (if different)
Phone #: *
Email Address:
Date of Birth: *
Head of Household SS #
(Quotation Purposes Only): 
Do you own:
Mortgage Balance:
Home Type:
Age of House:
Square Footage:
Have Basement:
Present Policy Limit:
Have Garage:
Have Trampoline:
Have Pets:
Type and Breed:
Have Pool?:
Do you have an underground oil tank?:
Do you have a central burglar alarm?:
Do you have a central fire alarm?:
How many feet do you live to the nearest hydrant?:
Name of current insurance co:
Policy Renewal Date:
Have you have any claims in the past 3 years?:
If yes, please describe: