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What is your zip code?
Do you own this property?
Yes
No
Do you already have an existing insurance policy for this property?
Yes
No
Who is your current insurer?
AAA Insurance Co.
Allstate
American Family
Country Financial
Farmers
Geico
Liberty Mutual
Nationwide
Mercury
Metlife
Progressive
State Farm
Travelers
Safeco
The Hartford
USAA
Other
What type of home are you insuring?
Single Family
Duplex
Multi Family
Townhome
Mobile Home
Condominium
What type of property is this?
Primary Residence
Seasonal Residence
Vacation Property
Rental Property
Number of stories?
1
2
3
4 or more
Number of bedrooms?
1
2
3
4
5 or more
Number of bathrooms?
1
2
3
4
5 or more
Type of Roof?
Asphalt Shingle
Wood Shingle
Tile Shingle
Metal Roof
Not Sure/Other
How old is your property?
1-10 years
11-20 years
21-50 years
Over 50 years
What is the square footage?
500 or less
501-1000
1001-1500
1501-2000
2001-2500
2501-3000
3001-3500
3501-4000
4001-4500
4501-5000
5001 or more
How much is the value of your home?
$100,000 or less
$100,000 - $200,000
$200,000 - $300,000
$300,000 - $400,000
$400,000 - $500,000
$500,000 or more
What is Your Gender
Male
Female
Are you currently married?
Yes
No
What is your Education Level?
Some or No High School
High School
Some College
Associate Degree
Bachelors Degree
Masters Degree
Doctorate Degree
What is your Occupation?
Banking/Mortgage
Clergy/Religious
Clerical
Construction/Facilities
CPA/Auditor
Customer Service/Teller
Disabled
Doctor/Dentist
Education/Training
Engineering/Architecture
Government
Health Care
Hospitality/Travel
Human Resources
Insurance
Internet/News Media
Law Enforcement/Security
Legal
Management Consulting
Manufacturing/Operations
Marketing
Military/Defense
Other
Pharmaceutical/Biotech
Programmer
Real Estate
Restaurant/Food Service
Retail
Retired
Sales
Skilled Worker
Student
Technology
Telecommunications
Transportation/Logistics
Unemployed
What is your date of birth?
First Name
Last Name
Email
Phone
Address
State
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UT
VT
VA
WA
WV
WI
WY
City
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