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Personal Information

First name:

Last name:

Telephone:

Current Address:

City:

State:

Zip code:

Email:

Occupation:

Home Information

Year Built:

Type:

Stories:

Construction:

Foundation:

Age of Electric: (years)

Age of Plumbing: (years)

Age of Heating: (years)

Basic Interior Features

Living Space (square feet):

# of Full Baths:

# of Half Baths:

# of Chimneys:

# of Hearths:

Additional Interior Features

Finished basement

Central air conditioning

Security system

Basic Exterior Features

Garage Type:

Garage Size:

Roof Type:

Roof Age:

Additional Exterior Features:

Deck

Screened-in porch

Outdoor pool (not fenced)

Outdoor pool (fenced)

Additional Information

I have a dog

I need additional jewelry coverage

I need additional fur coverage

I have a stamp or coin collection

I have firearms I want covered

I have antiques I want covered

I want additional computer coverage

Optional Coverages

Appliance breakdown	Earthquake
Flood	Identity theft

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Synergy Insurance Advisors
10800 E Geddes Ave Suite 120
Englewood, CO 80112
Phone: (888) 237-2920
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