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Independent Insurance Agent

Home Insurance

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Address Information
Name
Address
City State Zip
Home Phone  
 Work Phone
Email
Present
Insurance Co.
Present
Coverage Amount
Occupation
Claims in 
last 3 years		 0 1 2 3 4+
Square Footage of
Living Space		  

Year Home
was Built
Construction
Type Construction
1-Story Frame or Stucco
1 1/2 Story Masonry Veneer
2-Story Masonry
Split Level
Bi-Level
Foundation Roof
Basement Asphalt Shingle
Crawl Space Wood Shingle
Slab Tile or Slate
Other
Age of Roof
Garage Bathrooms
1-Car 2-Car 
 3-Car 4-Car		 # of Full
1 2 3 4 5
Attached Detached 
Basement Built-in
Car Port		 # of Half
1 2 3 4 5

Other Features
Central Air Conditioning Central Vacuum
Wet Bar Whirlpool Tub
Security System

Fireplace

Basements

# of Chimneys

Finished  Yes No

# of Heaters

Sq.Ft

Deck, Porch, Patio

Deck sq. ft.

Porch sq. ft.

Screened Patio sq. ft.

Enclosed Porch sq. ft.

Comments

For more information call us at 504.486.6133

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4700 Orleans Avenue · New Orleans, Louisiana 70119
Phone 504.486.6133 · Fax 504.482.3514
Email info@martin-agency.com