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Homeowners Quote


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information
First Name
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Last Name
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Street
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City
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State
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ZIP / Postal Code
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County
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Borough / Township
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E-Mail Address
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Primary Phone Number
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Alternate Phone Number
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Date of Birth
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/ /
Social Security Number
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Previous Address (if lived at current address less than 3 years)
Street Address
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City, State. ZIP Code
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Current Information
Do you currently have insurance?
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Current Premium
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Current Insurance Provider
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Months With Company
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Current Policy End Date
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/ /
Dwelling Information
Year Built
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Roof Type
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Construction Type
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Type of Heating
Required
Type of Electric
Required
Basement
Required
Is Basement Finished?
Optional
Garage
Required
Date of Original Purchase
Optional
/ /
Number of families living in home?
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Deductible Amount
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Square Footage
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Feet From Fire Hydrant
Required
Miles to Fire Department
Required
Estimated Value
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Dogs
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Pool
Required
Trampoline
Required
Business on Premises
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Claims/Property Losses in Past 5 Years (Please Explain)
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How did you hear about us?
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Submission Validation
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

Valley Agency Company
(717) 264-4311
797 Fifth Avenue - Chambersburg, PA 17201
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