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Personal Information

First Name
Last Name
Address
City
State
Zip Code
Daytime Phone
Cell Phone
Email Address
Occupation

Current Homeowners Insurance Information

Please fill out the following if you currently have insurance.

Insurance Company
Policy Expiration Date
Premium Amount
Amount Insured For

Home Information

How Long At Present Address
Year Home Was Built
Square Footage (excluding garage and basement)
Number Of Claims (last 3 years)

Structure Information

Type
Construction
Roof
Age Of Roof
Foundation
Garage

Features

Number Of Bathrooms (Full)
Number Of Bathrooms (Half)
Basement
Basement Square Footage
Basement Square Footage
Deck Square Footage
Patio Square Footage
Porch Square Footage
Number Of Chimneys
Number Of Hearths
Heating System
Central Air
Central Vac
Security Alarm
Fire Alarm
Smoke Detector

Additional Information

Comments

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Questions?

Please call us at 781-344-0098 or feel free to use our contact form.

John P. Russell Insurance, Inc.
65 Pearl Street
Stoughton, MA. 02072
Phone: (781) 344-0098
Fax: (781) 341-2563

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