"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: NH, ME, VT
	Homeowners Insurance Quote Request Applies to Homeowners, Renters, Condos, and Apartments Contact Information First Name Middle Initial Last Name Street Address Apt. # City State Zip Code Occupation Employer Email Address Phone Number ( ) - Date of Birth* (dd.mm.yyyy) 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 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? (Choose One) Single Family Home Duplex Mobile Home Apartment Condo Townhouse Other What type of construction? (Choose One) Frame Brick Adobe Steel Concrete What type of roof material? (Choose One) Tile Composition Shingle Tar and Gravel Wood Shake Other 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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