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Home Quote Form This is a secure form submitted over SSL. Click here to access the form in its own window. Name * Home/ Cell # Address/City/Zip Type * Select -> Homeowner Renter Landlord Smokers in Home? * Select -> Yes No Year Built * Square Footage * Rate your Credit History * Select -> Excellent Average Poor Roof Type * Select -> Tile Shingle Wood Other # of Stories * Select -> 1 2 3 4 # of garage spaces * Select -> 1 2 3 4 5 # of bathrooms * Select -> 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 Fireplace * Select -> Yes No Pool * Select -> Yes No Alarm System * Select -> Yes No Vaulted Ceilings * Select -> Yes No Deductible 250 500 750 1000 How many claims in the last 5 years? * Renovation? * Select -> None Roof Piping Electric SSN Date of Birth ( * Required Field )

Michael Van Insurace Agency
buyfarmers.com
3855 W Ray Rd Ste #2, Chandler, AZ 85226  | (480)899-0898 office  |  (480)899-1914 fax

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