Address of the home if different from above:

Age of home:

Have the plumbing, roof, wiring, and furnace all been updated in the past twenty years? Yes No

How much is the house insured for now?

Where is it insured?

Have you had any losses under your current homoeowner's policy? Yes No

How much are you currently paying per year?

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© 1997 East Lake Insurance Agency

2404 East Lake Road Erie, PA 16511 (814) 459-4380 Fax (814) 459-4583