Falkins Insurance
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Contact Information
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First Name:
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Last Name:
 
Home Phone:
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Email Address:
Policy Information
 
When is your current policy due for renewal?
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If no policy is currently in force, when do you require coverage to begin?
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*
Any claims or losses in the last 5 years?
Home Information
 
Street Address:
location to be insured
 
City/Town:
 
Postal Code:
 
What type of resident are you?
 
Do you have a mortgage?
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Year Built
 
Type of Construction:
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Dwelling Type:
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Heating Type:
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Is this your Primary residence?
 
How many stories to your home?
not including basements
 
Security Alarm:
 
Do you operate a business from your home?
 
Approximate square footage of the home:
 
Rebuild cost of your home:
(Rebuild cost is not the same as Market Value)
 
Are you part of a neighbourhood/block watch program?
 
Comments:
Additional Information
 
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How did you hear about us?
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