DG&M Agency Inc.

General Information

First Name:
Middle Initial:
Last Name:
Address:
Address:
City:
State:	Zip:
Phone:	Fax:
E-mail
Current Replacement Value or Current Amount of Insurance on Your Home:
Year Built:

Construction:	Wood Frame	Brick Veneer
	Masonry	Unknown

Own or Rent:	Own Rent
Total Replacement Cost of your Personal Property :
Fire Department/District:
Policy Deductible:
Personal Liability Limit:

To ensure you receive the best possible premium, please check all
that apply:

	Dead Bolt Locks	Fire Extinguisher
	Smoke Detectors	Central Station Fire Alarm
	Local Station Fire Alarm	Central Station Burglar Alarm
	Local Station Burglar Alarm	Non-Smoking Household

Do You Have Separate Valuable Items Policy?	Yes
If Yes please list the items scheduled under this policy:
Do You Have an Umbrella Policy:	Yes

For more information on our home products and companies, please contact: Karen Annechino

E-mail: kannechino@dgmagency.com

For information on our valuable items or personal umbrella products and companies please contact: Tessa Hewitt

E-mail: thewitt@dgmagency.com