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Smithwick & Clarke

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Chapman &
Chapman
P.O. Box 1030
Damariscotta, Maine
04543
Voice:
(207)563-3143
Fax:
(207)563-5424
Toll Free:
(800)370-3143

Home Owners Insurance Quote

Chapman & Chapman Insurance

Please begin by filling in your personal information. Filling out the form in it's entirety ensures an accurate quote will be provided.

Name

Address

CityStateZip

-Daytime Phone

Email Address

Occupation (s):

Street Address of Property:

Within 1000' of fire hydrant YN

Within 5 miles of Fire Station YN

Year House Built:

Year of improvements / updates:
Roof: Electrical System:

Circuit Breakers: Y N

Plumbing: Heating:

Type of Primary Heat:

Wood Stove: YN

Type of House:

Occupancy is Primary Home Seasonal Home
Is home ever rented to others? Y N

Coverage Requested:
Amount of Dwelling Coverage:

Amount of coverage for Detached Structures:

Liability Limit:

Medical payments:

Deductable:

Coverage Options:
Replacement cost contents.
Replacement cost dwelling.
Earthquake coverage
Flood Insurance
Back up of sewer or drain

Remarks: please include any special coverage items you are interested in, such as antique or jewelry schedules, etc.

Other Information I'm interested in:
Umbrella liability Insurance
Yacht or Boat Insurance
Recreational Vehicle Insurance
Motorcycle or Snow Mobile Insurance

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