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Home Owners Quotation Request
We are prepared to provide you with a no cost, no obligation
review and comparison of your insurance.

PLEASE NOTE:  To ensure an accurate quote, please fill in all areas.  If you prefer not to complete this form, you may obtain a quote by faxing your current Homeowners declaration page to 229-436-2110.

Name:       
County: 
Address:  
City:             State:  Zip:
Phone:       
Email Address

Home Information:

Inside/Outside City : 
Distance to Fire Station: 
Distance to Fire Hydrant:
Year Built
Number of Stories
Square Feet (Main Floor)
Fire Place Insert/Built In
Type of Heat
Baths Full/Half
Carport/Garage Number of Cars
Crawl Space/Slab
Porch/Deck/Patio Size
Supplemental Heat other than fireplace Type
Smoke Alarms
Dead Bolts
Fire Extinguisher
Central Station Alarm
Ever Filed Bankruptcy If So/When?
Pool Above Ground/Built in
Fence Around Pool? Locked Gate?
Amount of Coverage Desired
Deductible
Replacement Cost DWLG
Contents
If Dwelling is over 25 years old list updating to the following
Type Complete/Partial Year Done
Plumbing
Electrical
Heating
Roof
Do you Own Dogs
How Many Dogs
Breed(s)
Prior Insurance Company
Canceled/Not Renewed
If So, Why
Prior Losses
All companies require a credit report before writing coverage. In order to get the report, we must have your Social Security Number and Date of Birth
Name Social Security # Date of Birth

 

Home • Homeowners • Auto • Life • Business • Construction • Group
Related Sites • Our People • Insurance Tip • Contact Us
Copelan Insurance Agency, Inc.
2401 N. Slappey Blvd.
Albany Ga, 31701
1-888-224-4163
(229) 436-7736 •  Fax (229) 436-2110
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