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Please note that Styer & Evans Insurance Agency transacts business in Pennsylvania ONLY.

Fields denoted with * are required fields.

General Information

Name:  

 *
Social Security #:    (123-45-6789)
Address:  
(of home to insure)    		*
City:  
*

County/Township:   

State:   
PA

Zip:  

 *
Phone:   * (111-555-1212)
Email Address:    *
 

Home Information
Construction Type:  

If other, please specify:   

Age/Year of Construction:  
Home Type:  
Home Style:  
Square Footage:  

Number of Stories:   

Distance to Fire Hydrant:  

Miles to Fire Station:   

   
Does your home have any of the following?  (Please check all that apply)
 
  If yes, please explain: 
Any other Schedules/Items? (Jewelry, Furs, etc)?
  If yes, please list: 
Are there any other buildings on the premises?
  If yes, please list: 
Are there any other residences owned or rented?
  If yes, location(s): 
 

Updates
If your home is over 30 years old, please indicate the year updates were made to any of the below areas:
  Roof:    Type of update:
  Electric:    Type of update:
   

Type:   

Amps: 
  Heating:    Type of update:
  Plumbing:     Type of update:
      

Coverages
Please indicate the desired coverage for the following:
Dwelling:     
Other Structures:     
Personal Property:     
Loss of Use:     
Deductible for Property:    If other, please specify: 
Liability:    If other, please specify: 
Medical Payments:    If other, please specify: 
 
Comments
 


Notice of Licensure:  Styer & Evans Insurance Agency is licensed to conduct business in Pennsylvania.  The information
on this site is a solicitation to conduct business only in the aforementioned state(s) of authority.

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