MyPolicy.com - Personal Insurance - Dwelling Fire

Section One - Personal Information

Name:

Address:

City:

State: MA Only

Zip:

Telephone:

Fax:

E-Mail:

Date of Birth

Are you currently a Fitts Insurance customer? Yes No

Section Two - Home Description

Construction Type: Brick Frame

Year Built:

If the home is more than 20 years old, please advise the date that the following items were updated:

Plumbing:

Heating:

Electrical:

Roof:

Living Space Area: square feet

Style of House:

Number of Families:

Please select all that apply to your home:

Local smoke detectorLocal burglar alarm

Centrally monitored fire alarmCentrally monitored burglar alarm

Deadbolt locksFire extinguisher

Water leak alarm

Section Three - Coverage Limits

Dwelling:$

Contents (if any):$

Liability:$

Deductible:$

Select any additional coverage options:

Loss of rentsMonthly rent per unit:

EarthquakeOrdinance/law coverage

Section Four - Claims History

How many years have you owned this building?

How many years have you been loss free at this location?

Please describe all claims that you have incurred in the last ten (10) years:

Section Five - General Information

Do you own any recreational vehicles such as boats, snowmobiles, golf carts, ATV's, motor homes,, etc? Yes No

Do you own any additional residences? Yes No

Do you have a wood stove? Yes No

Do you have a swimming pool? Yes No

If so, is the pool completely within a fence enclosure? Yes No

Does the pool have a slide? Yes No

Does the pool have a diving board? Yes No

Has this building been deleaded? Yes No

If so, do you have certificates? Yes No

Current policy expiration date:

Please indicate how you found our web site:

Prior Fitts Insurance Customer
Referral/Word of mouth

Please tell us who referred you:

Newspaper advertisement
Internet banner advertisement
Radio advertisement
Yellow Pages
Internet Search Engine

Google
Yahoo
Altavista
Webcrawler
Lycos
Other :

Other

Any additional comments: