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719-275-0305
1116 Main St, Canon City, CO 81212
manager@myaffordableco.com
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AFFORDABLE INSURANCE
TELEPHONE LEAD
AFFORDABLE INSURANCE TELEPHONE LEAD
DATE
Owner 1:
DOB
Owner 2:
DOB
Email
Home #:
Work/Cell #
Marital Status
M
S
Div
Sep
W
Previous Address if not at above for five years
Previous Insurance Cancelled or Non-renewed?
Yes
No
If yes, why?
# of claims in last five years
Type
Date
Any Dogs
Yes
No
If so, what breed?
Bite History
Yes
No
Current Comapany
How Long?
Current Premium
Renewal/Purchase or closing Date:
Mortage:
Yes
No
Escrow?
Yes
No
Yr built
Total Sq. Ft.
Style
RANCH
BI-LEVEL
TRI-LEVEL
VICTORIAN
BUNGALO
CONTEMPORARY
SINGLE-WIDE
MULTI-WIDE
COLONIAL
Checkbox
Basement
CS
Slab
Brick
Frame
Stucco
Type of Exterior
STUCCO
WOOD SIDING
CLAPBOARD
VINYL SIDING
BRICK
Dwelling Account
Manufactured/Mobile Year/Make/Model/Serial Number of Manu/ Mobile Home
# of Baths
# of Bdrms
Garage:
Yes
No
is it attached?
Yes
No
# of Cars
Main Source of heat
Main Source of Cooling
Fireplace
Yes
No
chkc1
Shingle
Metal
3tab
Tock
Age of Proof
Home older than 20 yrs? Year updated on:
Heating
Plumbing
Within City limits
Yes
No
Mi. to Fire Dept.
Business on premises:
Yes
No
Type
Chckbox
Dead Bolts
Fire Exit
Smoke Alarm
Security System
Tock
Decks, Balconies, Patios or Porches:
Sq. Ft.
Detached Structures:
Other Information
Results/Additional Results
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Contact Us Today
Phone:
719-275-0305
E-mail:
manager@myaffordableco.com
Address:
418 Main St, Canon City, CO 81212
Hours of Operation
Mon - Fri
9:00 am
-
5:00 pm
Sat - Sun
Closed
Contact Us Today
Phone:
719-275-0305
E-mail:
manager@myaffordableco.com
Address:
418 Main St, Canon City, CO 81212
Hours of Operation
Mon - Fri
9:00 am
-
5:00 pm
Sat - Sun
Closed
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HOME
Auto Insurance
SR22's
Home Insurance
Commercial/Business
Specialty Insurance
About Us
Meet the Staff
Contact Us
Contact Us Today
Phone:
719-275-0305
E-mail:
manager@myaffordableco.com
Address:
1116 Main St, Canon City, CO 81212
Hours of Operation
Mon - Fri
9:00 am
-
5:00 pm
Sat - Sun
Closed
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