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Brady Renners
& Associates
Insurance Agency, Inc.

4946 Dixie Hwy
Fairfield, Ohio 45014

PHONE: 513-874-7949
FAX: 513-874-7879
bradyrennersins@cinci.rr.com

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Personal Information


Name:
 
Spouse Name:
 
Address:
 
City:
 
State:
 
Zip Code:
 
County:
 
Township:
 
Best Way to Contact:
 
Home Phone:
 
Work Phone:
 
Cell Phone:
 
Email:
 
 

Date of Birth

Insured
 
Spouse
 
Your SSN#:
 
Spouse SSN#:
 
Marital Status
 
Residence
 

 

How did you hear about us?
 
If "Other", please list:
 

 

Are you currently insured?
 
Current insurer:
 
How long insured with current company?
 

Home Information

Has your insurance ever been cancelled?
 
Number of claims on any property that you've owned in the last 5 years:
 
Please describe any claims:
 
     
Dwelling Construction:
 
(If "other" please describe):
 
Style of Home:
 
Approximate Square Footage of Home:
 
Distance to Fire Department:
 
Distance to Fire Hydrant:
 
What year was your home built?
 
Is your basement:
   
Full
 
  Percent:
Slab
 
  Percent:
Crawl Space
 
  Percent:
Other
 
  Percent:
Basement:
 
Percent Finished
 
Do you have a fireplace in your home?
 
  Type:
Do you have a fireplace insert?
 
Do you have a wood burning stove?
 
Is wood burning stove insert UL listed?
 
Has the chimney been cleaned in the last year?
 
Do you use any other heat sources in your home?
(ex: space heater, kerosene heater)
 
Any animals or pets? Please list type, breed, and number?
 
Do you have a trampoline?
 
Do you have a pool?
 
  Type:
Does the pool have a slide or diving board?
 
If you own a pool is your yard completely fenced?  

Please check all alarms that apply

Dead Bolts
 
Central Fire Alarm
 
Central Burglar Alarm
 
Smoke Detector
 
Fire Extinguisher
 
   
Do you have any jewelry scheduled?
 
If yes, what amount?
 

Optional Coverages: Check all that apply

Sewer & Drain Backup
 
Earthquake
 
Flood
 
Life
 
Umbrella
 
Identity Theft
 
Other
 

Updates of Home

Age of Roof:
 
Age of Furnace
 
Last update to plumbing:
 
Plumbing is:
 
Last update to electrical system:
 
Electric is:
 
Does the home have any knob or tube wiring?
 
If new home purchase, please list purchase price or market value:
 
Have you purchased your home in the last 12 months?
 

Please indicate current coverage amounts:

Dwelling Coverage:
 
Personal Property:
 
Personal Liability:
 
Other:  
   
Medical Payments:
 
Other:
 
   
Deductible:
 
Other:
 

*Renters / Condos Only*

Dollar amount of coverage to be placed on personal property:
 
If "Other" please describe:
 

* Our best prices are provided to those you combine both their auto
and home insurance with us. Ask about our auto home discount.

Additional Information Box:
 
IMPORTANT!: Please note that we cannot bind, delete or change coverage from an email or online request. Someone from our office will contact you to confirm changes.

 
 
Brady Renners & Insurance Agency, Inc 2008 | Privacy Policy |      4946 Dixie Hwy Fairfield, Ohio 45014    PHONE: 513-874-7949   FAX: 513-874-7879
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