Your Name:
First::
Last::
Email Address:
Phone Numbers:
Daytime:
Evening:
Fax:
How would you prefer to be contacted
regarding your quote?
Phone
Fax
Mail
E-Mail
If you would prefer to be contacted by phone,
please let us know the best time to call.
Address:
City:
State:
Zip Code:
Do you currently own your home, or rent?
Own
Rent
Driver's license number:
Social Security number:
Dwelling Value
(does not include land value)
Year Built
Number of Stories
Select One
One
Two
Three
Square Footage
Type of Construction
Select One
Frame
Joisted Masonry
Central Station Burglar Alarm
Select One
Yes
No
Dead Bolt Locks
Yes
No
Fire Extinguisher
Yes
No
Smoke Detectors
Yes
No
Is the house in a subdivision?
Yes
No
Age of the owner(s)
Value of jewelry to be covered?
Value of any special art, furs, silver, etc.
Is there a business in the house?
Yes
No
900 N. Herritage St. / P.O. Box 98 Kinston, NC. 28502
Phone: (252) 523-2177 Toll Free: (800) 849-1832 Fax: (252) 523-7217
Kinston Insurance Service Agency, Inc.
E-mail us
with questions
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