Soucy Insurance Agency

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Quick Quote - Homeowners

Please provide the following information:

General Information

Date: First Name: Last Name:

Email Address: Social Security Number:

Mailing Address:

City: State: Zip:

Daytime Phone: Work Phone:

Property Address (If Different)

Home Information

Style of Home: (I.E. Cape, Colonial, etc.):

Year of Construction:    Pre-1950 Upgrading Info. (Please provide year)

Number of Families:             Roof:          Plumbing:

Construction:         Wiring:           Heating:

Policy Information

Date present policy expires or new policy takes effect:

Present Dwelling Limit:  Present Liability Limit:

Present Deductible:  Replacement Cost Contents Coverage:

Personal Umbrella Coverage:   Earthquake Coverage:

Scheduled Items - Type and Value:
(i.e. Jewelry, Furs)

Underwriting Information

Any Business Conducted on the Premises:

If YES, briefly describe:

Any Smokers in the House:

Any Animals:   If Yes, Type/Breed:

Is There a Coal or Wood Stove:

Is There a Swimming Pool: If Yes: In ground:Above Ground:
                                           Fenced:

Any Losses in the Past Three Years:

If Yes, Please Describe and Include Amount Paid:

Additional Comments:

You will be contacted by an agent within 24 hours.

We give the Best Service and give the Best Prices on all lines
of insurance. We also have available pay plans, multi policy
discounts, and credit card services .