George Doakmajian Insurance Agency
George Doakmajian Insurance Agency

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Name:
email:
Property Address:
Phone Number:
Market Value
# Family Dwelling
Dwelling Type:
 Ranch    Colonial    Saltbox
Split Level    Row House
Other:
# Bedrooms:
# Bathrooms
# Fireplaces or Woodstoves
Year Built:
Construction Type:
# Stories
Square Feet:
Foundation Type:
Located in a flood zone?
 Yes No
Garage Type:
Roof Type:
When was the roof updated?
Is there a pool?
 Yes No
If yes -  
 		 Is it fenced? Yes No
Is fence lockable? Yes No
Is there a diving board? Yes No
Is there a slide?: Yes No
# Miles from Fire Dept:
Does the house have:
  
Smoke alarms?
 Yes No
Fire extinguisher?
 Yes No
Deadbolts?
 Yes No
Electrical Updates?
 Yes No
Circuit Breakers?
 Yes No
Central Air?
 Yes No
What type of heating?
Is the plumbing updated?
 Yes No
Is there a theft alarm?
 Yes No
What fire district?
Do you have a trampoline?
 Yes No
What is the current insurance company?
Have there been any claims or losses in the last 5 years?
 Yes No
If so, give date, amount paid, and description of loss:
DESIRED COVERAGE INFORMATION
Dwelling amount:
Other structures:
Personal property:
Loss of use:
Liability:
Deductible:
   
Do you want replacement cost coverage? Yes No
Do you want contents replacement cost coverage? Yes No
Do you want sump pump failure and water backup coverage?
Yes No
Do you want identity theft coverage? Yes No


Please note: Insurance coverage cannot be bound without a written binder from our office.
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