AMERICAN INSURANCE AGENCY

Homeowners/Tenants Insurance Quote Form Massachusetts Only

Massachusetts Home, Condo & Renters Quote

Type of Insurance	Please Select Home Owners Condominium Insurance Renters /Apartment Insurance
Name
Street Address
City
State:
Zip
Daytime Phone
Email Address

Home Owner Information
How Long At Present Address:	Year Home Was Built:
Approximate Size of Living Area (if known):	sq. ft.
# of Claims in Last 6 Years:

Structure Information
Type	Construction	Roof	Basement	Garage
1 Story 1 1/2 Story 2 Story Split Level Bi-Level Other	Frame Masonry Masonry Veneer Aluminum Siding Plastic Siding Asbestos Siding Other	Asphalt Shingle Wood Shingle Tile or Slate Other	Finished Unfinished Crawl Space Slab Other	1 Car 2 Car 3 Car 4 Car None
Number of Units If Condo or Apt:		Age of roof: yrs.		Garage Type: Attached Detached Basement Built-in Car Port None
Renovation Information Type Partial Complete Year Wiring Plumbing Heating Roofing Exterior Paint

Additional Features
Security Alarm	Fire Alarm	Smoke Detector
None Monitored Not Monitored	None Monitored Not Monitored	Yes

Coverage/Limits of Liability
Dwelling
Other Structures
Personal Property
Loss of Use
Personal Liability (each occurrence)
Medical Liability (each person)
Replacement Cost Information
Cost of dwelling (i.e..$225,000)
Cost of contents

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Last updated December 16,2010

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