<p> Dwelling Insurance Quote Fax to Yates Insurance706 675-6622</p><p>Owner’s Name______Date of Birth ______Social Security # ______Co-Owner’s Name ______Date of Birth ______Social Security # ______Mailing Address______Phone______Property Address______Age of Home______Dwelling Information: Use: Rental Owner Occupied Vacant City Limits? Yes No If Rental, Landlord Package? Yes No Screen Tenants? Yes No Construction Type: Frame Brick Log Mobile Home Type of Siding: ______Mobile Home? Year ______Make______Model ______Length/Width ______Additions to Mobile Home: Yes No Explain:______Underpinning: Block Vinyl Metal Other______Decks? Length/Width ______Foundation: Basement Slab Crawl Space Number of Families: ______Outbuildings? Shed Barn Garage (attached / unattached) Dimensions: ____ x _____ Primary Heat Source: Furnace- Gas or Electric Heat Pump Fireplace Space Heaters Purchase Date of Home: ______Market Value: $______Square Ft: ______Amount of Insurance on Dwelling: $______Personal Property $______Year Updated: Plumbing______Electrical______Heating ______Roof______Roof Type: Asphalt Wood Metal Slate Other______Security Devices: ___ None ___ Smoke Detectors ___ Central Fire Alarm ___ Dead Bolts ___ Fire Extinguisher ___ Sprinkler ____ Burglar Alarm Any Claims? Yes No If Yes, Date: ______Explain: ______Mortgagee Clause: ______Escrow Bill? Yes No</p><p>You may qualify for special discounts if you have more than one line of business with our agency. Would you like? Auto Insurance Quote? Yes No Life Insurance Quote? Yes No Do you own a Boat? Yes No Do you own a Motorcycle? Yes No Quotes: Company Six Month Annual Down Payments ______</p><p>______</p><p>______</p>