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General Information
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First Name	*
Last Name	*
Email	*
Phone:

How old is your roof?
What type of roof is on your house?
Type of heat in your home?
Do you have a wood stove?	Yes No
What year was your plumbing last updated? (if ever)
What year was your electrical wiring and/or service last updated? (if ever)
Have you made any additions to your home?	Yes No
Would you be open to a higher deductible to save you money?	Yes No

Comments or Other Instructions