Phone: 215-997-5800
Fax: 215-997-9887
info@hartzellinsurance.com
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Contact Information
Name
Email:
Phone:
Fax:
Street Address:
Street Address 2:
City:
State:
Zip Code:
Occupation:
How Long At Current Occupation:

Current Homeowners Insurance Information
Company:
Policy Expiration Date (mm/dd/yy):
Annual Premium:
Amount Insured For:
Policy Form:  Renter  Condo  Home

Home Information
How Long At Current Address:
Year Home Was Built:
Sq. Footage (excluding garage and basement):
Number of Claims in Last 3 Years:
Property Address (if different):
Fire Hydrant within 1000 ft:  Yes  No
Fire Dept:  Within 5 Miles  Over 5 MIles

Structure Information
Number of Stories:
Structure Is A:  Town House  Row House
Roof:  Asphalt Shingle  Built Up Rubber
Age of Roof (yrs):
Flat Roof:  Yes  No
Foundation:  Basement  Crawl Space  Slab  Other
Garage:  1 Car  2 Car  3 Car
Garage:  Attached  Detached

Structure Information
Number of Full Bathrooms:
Number of Half Bathrooms:
Basement Is Finished:  Yes  No
Square Footage of Basement:
Number of Chimneys:
Number of Hearths:

Additional Information
Heating System:  Gas  Electric  Underground Oil  Aboveground Propane
Central Air:  Yes  No
Central Vac:  Yes  No
Security Alarm:  Central  Local
Fire Alarm:  Central  Local
Smoke Detector:  Yes  No
Deadbolt:  Yes  No

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Hartzell Insurance Associates, Inc.
2501 N. Bethlehem Pike (Rt. 309)