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(740) 927-1469
30 S Township Rd Ste B
Pataskala, OH 43062
Click Here to Email Us
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Indicates required field
Type of Home
*
Single Family Home
Duplex
Townhome
Mobile Home
Other
Year Built
*
Fire Alarm
*
None
Monitored
Unmonitored
Not sure
Number of Units in Your Complex?
*
1
2
3
4
5+
How is the Property Occupied?
*
Principal
Seasonal
Secondary
Long Term Rental
Vacant
Under Construction
Number of Rooms
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1
2
3
4
5
6
7
8
9
10+
Square Footage
*
Security System
*
None
Monitored
Unmonitored
Unsure
Within 5 Miles of a Fire Station?
*
Yes
No
Within 1000 feet of a fire hydrant?
*
Yes
No
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Name
*
First
Last
Select any additional property features that apply.
*
Dead Bolts
Fire Extinguishers
Tramploline
Covered Deck/Patio
Swimming Pool
Indoor Fire Sprinkler
Have you reported any claims or losses to your insurance company within the past 5 years?
*
Yes
No
Do you have any of the following breeds of dogs: Chow, Doberman, German Shepherd, Pit Bull, Rottweiler, Wolf Hybrid, or a mix of these?
*
Yes
No
Is any business conducted on the property?
*
Yes
No
Personal Liability Coverage Desired
*
$100,000
$300,000
$500,000
$1,000,000
Other
Desired Deductible
*
$250
$500
$1000
$2000
Other
Will this insurance replace an existing policy?
*
Yes
No
When would you like this policy to start?
*
Credit Rating
*
Excellent
Good
Poor
Unsure
Email
*
Phone Number
*
Additional Comments?
*
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