Griffin Insurance Agency, Inc.

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Insurance Quote Request

Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me.

Information

Name:

Address:

City:

State:

Zip:

Day Phone:

Beeper:

Eve. Phone:

Cell Phone:

E-mail Address:

Best Time To Contact:

AM PM

Method of contact:

Day Phone Eve. Phone Beeper
Cell Email

Current Policy Information

Agent:

Insurance Company:

Policy Number:

Policy Expiration Date:

Dwelling Information
# of Stories:
Construction:
If "Other", specify:
Additional Info:
Property Secondary Residence	Yes No
Is Property Occupied by:	Owner Tenant
Tenant Content:	Yes No
Type of Roof:
If "Other", specify:
Roof Covering:
If "Other", specify:
Garage:
Attached Porches/Carports:
Foundation Type:
Amount of Insurance Requested on Dwelling:	$ (Replacement Cost, not Market Value)
Distance from water &/or Coastal Exposure:
Distance from Fire Department &/or Hydrant:
City Limits:	Inside Outside
Business Pursuits on Property:

Utilities Updated in the last 20 Years:
Heating:	Yes No	Year Updated:
Wiring:	Yes No	Year Updated:
Roof:	Yes No	Year Updated:
Plumbing:	Yes No	Year Updated:
Full Circuit Breakers:	Yes No	Year Updated:

Amenities
Number of Bathrooms:
Basement:	Yes No
Deck:	Yes No
Porch:	Yes No
Patio:	Yes No
Number of Fireplaces:
Central Air:	Yes No
Security Alarm:	Yes No
Fire Alarm:	Yes No
Smoke Detector:	Yes No
Hurricane Shutters:

Additional Information Section
In the box below, please provide any additional information you feel may be necessary for us to provide you with the best quote possible such as additional operators, coverages extenuating circumstances, etc.

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