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Contact Information

Full Name

Mailing Address

City
State     Zip:
Phone
E-mail Address
Current Policy Information
Policy Expiration Date
Amount of Coverage
Contents Coverage
Home, Condo & Renters' Insurance
Occupancy
Dwelling Type
Year Built
Square foot of home  
Amount of Insurance Requested
Have you reported any losses or claims in the
last 5 years?		 Yes  No
 Type of Claim
 Amount of Claim
Construction Type    other
Number of Fireplaces
Number of Rooms
Garage Type
Any other structures on property not attached to house? Yes  No
Any Smokers in House? Yes  No

Features
Swimming Pool Yes  No
If yes, is it fenced? Yes  No
If yes, diving board?Yes  No
Plumbing Updated Yes  No  If yes, year
Heating Updated Yes  No  If yes, year
Type of Heating  
Electrical Updated Yes  No  If yes, year
Electrical Type Circuit Breakers  Fuses
Roof Updated Yes  No  If yes, year
Do you have a trampoline? Yes  No
Wood Stove Yes  No
Any Pets? Yes  No
If yes, describe

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97 Center Street, Chicopee, Massachusetts 01013  •  phone 413-594-5984  •  fax 413-592-1142
Copyright Phillips Insurance Agency, Inc. 2004