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SCM Insurance

3858 Main Street Bridgeport, CT. 06606

Phone: (203) 374.9453
Toll Free: 888.866.6099
Fax: (203) 365.0406

Open from 9:00 AM to 5:00 PM weekdays


Homeowners Request A Quote

No coverage is bound until after all information is reviewed and application signed.

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

 
Social Security:
 (Optional)

..............................................................................................

What year was the house built:
Construction of home:
How many families is your home:
Is this your primary residence:
If this is new house what is the closing date:
If this is a new purchase what is
the moving date:
How many bedrooms:
How many bathrooms:
How many half-bathrooms:
What is the square footage:
How many floors:
What type of basement:
Do you have a fireplace:
Do you have attached garage:
Do you have a porch or deck:
What is the primary source of heat:
Do you have central air conditioning:
Do you have a security system:
Do you have a woodstove:
Have you had any losses in
the past 5 years:
  (if YES please fill in box below)
If YES to previous question please briefly describe the details:
Do you have current
homeowners insurance:
  (if YES please fax us the main page)
Do you have any dogs or other pets:
  (if YES please fill in the box below)
If YES to previous question please briefly describe your pet:
Do you have a swimming pool:
How far are you from the shore:

Prior to 1970 when were the following items updated?

Plumbing system:
Heating system:
Roof:
Electrical system:
. .
Type of electrical system:
Purchase price:
Total mortgage amount borrowed:
Comments and/or additional coverage you would like:
   

 

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