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   "Offering Complete Insurance Services Since 1887"  
Vaillancourt & Woodward
15 Exchange St
PO Box 8
Berlin, NH 03570
(603) 752 - 2440
(800) 734 - 3166
Fax: (603) 752 - 2583
Hours of Operation
Monday - Friday
8:30 am - 4:30 pm
Licensed In:
Homeowners Insurance Quote Request
Applies to Homeowners, Renters, Condos, and Apartments
Contact Information
First Name
Middle Initial
Last Name
Street Address
Apt. #
Zip Code
Email Address
Phone Number ( ) -
Date of Birth* (
Social Security Number
- - (xxx-xx-xxxx)
Do you have a spouse? Yes No

Current Insurance Information
Insurance Carrier
Expiration Date

Rating Information
What year was the dwelling built?
What type of dwelling?
What type of construction?
What type of roof material?
How old is the roof?
Square Footage of dwelling
Number of stories (floors)
Number of bedrooms
Number of bathrooms
Garage type Attached Detached
Garage - Number of cars
Do you have? (check all that apply) Pool Deck Spa
Other outdoor buildings
Is the wiring upgraded? Yes No
What year was the wiring upgraded?
Is the Plumbing upgraded? Yes No
What year was the plumbing upgraded?
Do you have a wood stove? Yes No
Do you have a fireplace? Yes No
If yes, what type of fireplace?
What is the primary source of heat?
What is the secondary source of heat?
Do you have a security system? Yes No
If yes, describe the type of security system.
Have you had any losses in the past 3 years? Yes No
If yes, please describe each loss.
Do you own any pets? Yes No
If yes, please list all your pets.
Special Coverage Needs
Please add any information about special circumstances or coverage needs. Include information about any Fine Arts, Jewelry, Coins, Guns, Safes, or Other Collectibles.
Does your home have any "special features"?

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