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Asia Insurance Renters/Apartments/Condo Quote

Customer Information
First Name	Middle Initial	Last Name
Street #	Street Name	Apt or Unit
City	State	Zip	-
Home Phone	Mobile Phone	Email

Insurance Information
This Quote For	Home Owner	Renter
Do you Currently Have Home Insurance ?	Yes No
When does your current policy expire?	Who are you currently insured with?
Year of Purchase	Price of Purchase
Loan Amount	Monthly Rent (if rental)
Year Built (approximate)	Interior Square Footage (approximate)

	Yes	No		Yes	No
Home located within 1,000 feet of a fire hydrant?			Home located within 5 miles of a fire station?
Home is susceptible to flooding or high water?			Home built on a hillside?
Is Your area prone to landslides and/or sinkholes?			Home located within a brush hazard area?
Do you have a dog?			Are there any firearms in your home
Is there a central alarm system?			Have you experienced any losses or filed any claims within the last 5 years?

No. of Stories	No. of Rooms		No. Persons
No. of Bathrooms	No. of Bedrooms		No.of Fireplaces
Type of Roof	Age of Roof		Type of Foundation
Type of Exterior Wall	Do You Have Basement?	Yes No	Do You Have a Gaurage?	Yes No
Which part of the year is the Home is occuppied?		Rate Your Own Credit

Please use the space below to add comments regarding any special circumstances or coverage needs

Yes, I am interested in:
	Health Insurance	Life Insurance
	Dental Insurance	Homeowners Insurance
	Disability Insurance	Renters Insurance
	Disclaimer	I wish to receive email offers

Disclosure

Where permitted by law, the insurance companies we quote will individually confirm your information through consumer reports, which may include credit reports. Each company will provide the source of the report if you are interested. Your information may be shared with the quoting company's affiliated underwriting companies, independent representatives or other insurance partners.

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