Tucson Insurance Agency


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Name:
Your Date of Birth:
Spouse Name:
Spouse Date of Birth
Street Address:
City:
Zip:
Phone:
Email:
Property Description:  
Year Built:
Material Made Of:
If Other, Describe:
Sq. Footage:
# of Stories:
Garage (cars):
# of Baths: (Use .5 for half bath)
Gas Furnace: Yes No
Renovations Done: Yes No (If Yes, enter year below)
What Year:
# of Fireplaces:
Deck or Porch: Yes No
Roof Type: Peak Flat
Roof Material:
Roof Age:
Air Conditioning:
Is there a Basement: Yes No
Percentage of Basement Finished:
Polybutylene Plumbing: Yes No
Smoke Detectors: Yes No
Fire Extinguishers: Yes No
Dead Bolt Locks: Yes No
Burglar Alarm: Yes No
Floaters on current policy: Yes No (If Yes, describe below.)
What Are They:
Closest Fire Department: (If Other, describe below)
Other:
Current Insurance Agency:
Since:
Any Losses or Claims: Yes No (If Yes, describe below)
What Were They:
CURRENT COVERAGES
Purchace Price:
Separate Structures:
Personal Property:
Loss of Use:
Personal Liability:
Guest Medical:
   
Referred By:
Estimated Closing Date:

 

 

 

 

 
Shestko-Montiel Insurance Agency
648 N. Stone Ave
Tucson, AZ 85705
Phone: 520-624-3309
Fax: 520-624-7064
Email: lshestkomontiel@allstate.com