A Full Service Agency
662 Riverdale St, West Springfield, MA 01089
413-732-4137, 800-642-9386, fax 413-731-6629
Hours 8:30 AM to 4:30 PM Monday - Friday

To obtain a individual quote please call, fax or send us a copy of your homeowner policy or complete the following form. We offer a 10% to 15% discount when we provide both your home and auto with the same company.

Name:
Street:
City:
State:
Zip Code:
Phone Number:
Fax:
E-Mail:
Best Time To Call:
Quote Is For:	Homeowner Tenant Condominium

Coverages

Dwelling:
Other Structures:
Personal Property:
Loss Of Use:
Personal Liability:	100,000 300,000 500,000 1,000,000
Medical Payments:	1,000 2,000 5,000 10,000
Deductible:	100 250 500 1,000 2,500

Information About Your Home

Type Of Construction:	wood frame brick/masonry
Year Built:
Number of Families:
Smoke Detectors:	Yes No
Burglar Alarm:	Yes No
Swimming Pool:	Yes No
Wood Stove:	Yes No
Dog:	Yes No Breed:
Smoker in the House:	Yes No
Year Of Updates:	Wiring: Plumbing: Roof: Heating:
Have you filed a home owners claim in the last 10 years?	No Yes If Yes: Date, Type, Amount Paid To You
Current Insurance Company:
Current Agent:
Renewal Date:
Premium:
Additional Comments:

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