Garber Atlas Fries & Associates, Inc.

Contact Name*
Email*
Phone Number
Address
City
State
Zip
County
Company Name
Current Annual Premium
Expiration Date
Deductible Desired
Amount of Liability
Earthquake Coverage Desired?

YesNo
Have you filed for bankruptcy within the past 7 years?

YesNo
Estimated Replacement Cost
Square Footage
Year Constructed
How Many Floors?

1 Story1.5 Story2 StoryBi-LevelTri-LevelOther
Type of Construction

WoodStuccoMasonryBrick VeneerAluminum SidingOther
Other Features ( Check all the apply )

Dead BoltsSmoke DetectorsFire ExtinguisherCentral Station Fire AlarmCentral Station Burglar AlarmHome Located within 5 miles of Fire StationHome Located within 1000 feet of a Fire HydrantSwimming PoolTrampolineHome located within City Limits
List any claims in past 3 years:
1
Estimated value of your personal property:
Jewelry & Watches
Furs
Silver
Firearms
Stamp and Coin Collections
Fine Arts and Breakable Items
* = Required Field

Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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