Home Insurance
We provide coverage in the State of Maine and New Hampshire.
Please fill out this form and we will search for the best value for you.  We will respond promptly to you.

 

First name

 Last name

Employer

Address

 City
 State
 Zip code
Home Phone
Work Phone
FAX
 E-mail
       
How would you prefer we contact you?
How did you hear about Bragdon Insurance?
Current Insurance Co.
Annual Premium $
Expiration Date  -- mm/day/year
DWELLING INFORMATION:
Choose one of the following options: 		 
Home  Apartment

Condo Other (specify):

Mobile Home    
 
Is this a single family home
Yes
No If no, # of families:

Do you:   

 own rent  
Is it: 
 primary

secondary

Choose one of the following options:
frame   brick   other (specify):

Select all of the following that apply:		  

alarm
deadbolt
fire extinguishers
woodstove
pool
   
Smokers in Household? Y / N

pets - breed:
trampoline
prior claims
mortgagee

Name & Address of Mortgagee:

Type Heat:
Oil    Gas        Other 

Year of construction (yyyy)
Indicate year of update if different from year of construction:


Heating System: (yyyy)

Wiring: (yyyy)

Plumbing: (yyyy)

Roof: (yyyy)

COVERAGE (REFER TO CURRENT POLICY)

Replacement Value of Home (house, Mobile Home)
$

Replacement Value of Contents (if renters or condo)
$


Select any of the following
options desired:
water backup
business in home
flood
earthquake coverage

scheduled items (jewelry, cameras, fine art etc)

Comments

Umbrella/Excess Liability Insurance
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