Mays Tucker Homeowners Quote

Your Independent Erie Agent for Auto - Home - Business - Life

	HOMEOWNERS QUESTIONNAIRE
	Please type in the ID Number, below, exactly as it appears here: mt01
* = Required	* ID Number:
	* Name:
	* Day Phone #:
	* E-Mail Address:
	Property Location:
	Construction Type: Brick Frame Other:
	Age of dwelling and/or year built:
	Any updates within the last 10 years? If so, describe:
	Heat Electric Plumbing Roof
	Is it within 1000 feet of fire hydrant? Yes No
	Distance to nearest fire department:
	Primary heat source: Heat Pump Oil-Gas Furnace Baseboard
	Other?
	Do you own a Wood Stove? Yes No . If Yes, was it professionally installed? Yes No
	Approximate square footage of home:
	1 Story 1 1/2 Story 2 Story Other
	Basement: Full Partial None Finished Unfinished
	Current Insurance Company (Not Agent):
	Current Amount of Coverage:
	Any losses or claims in past 5 years? Yes No
	Is there any business conducted on premises? Yes No . If Yes, please describe:
	Type of business:
	Your Comments:

Mays Tucker Insurance
Suite 102, 1744 S. Amherst Highway
Amherst, VA 24521-3369
434-946-2131
434-263-8120
Fax: 434-946-9242
Email: maystucker@msn.com