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Free Ranch & Farm
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!
Your Personal Data:
 
Your Name:
Property Address:
City:
Select State:
Zip/Postal:
E-Mail (REQUIRED):
E-Mail
(again for accuracy):
Phone:
Fax (optional):
 
 
Dwelling Information
 
Year Dwelling Built:
Home Square footage:
 
Number of units: 1 family Duplex
Triplex Four Units
 
Occupancy: Owner Tenant
 
Type foundation: Slab Crawlspace over slab
Pier & Post Other (list in remarks)
 
Type Roof: Shingle Wood Shake
Tar/Gravel Spanish Tile
Metal Other
 
Number of stories: One 1.5
Two Three
 
Do you own animals or pets? Yes No
If yes, list type/for dogs, list breed:
 
 
# of feet to nearest
fire hydrant: 		# of miles to nearest
fire station:
 
Currently Insured? Yes No
Name of Carrier & how long insured?
 
Prior Claims? Yes No
Describe claims in detail:
 
 
Circuit Breakers or fuses? Breakers Fuses

# Bedrooms: # Bathrooms:
 
# Fireplaces: # Chimneys:
 
Special features
(i.e., deck, air conditioning, alarm systems, pool, etc.)
 
Coverages:
 
Dwelling Cov. $ Contents $
Liability Cov. $ Deductible $
($250, $500, $1,000, etc.)
Barn Coverage Limit $
 
Comments/Remarks
(describe any scheduled jewelry, in-home business, or other special coverages needed here):
 
 
Farmowner Underwriting Information:
 
How Many Acres? Type of Farm?
(dairy, horse, etc.)
 
Total Number of Animals? Estimated equipment value?
 
Describe Growing Operations
(describe in detail your experience, type of operations, and coverage needed):
 
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Thank you for visiting the insurance web site of Taylor-Moore Agency, Located at: 346 Main St., Derby, Vermont
Mailing Address: PO Box 10   Derby, VT 05829  |  Local Phone: 802-766-2294   |    Toll-Free: 800-499-2294
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