Saugus Financial Insurance Agency - An Affiliate of Saugus Federal Credit Union

Name:

Date (MM/DD/YYYY):

Property Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Coastal: Choose Yes No

Distance from beach:

Applicant Information:

Email:

Birth Date (MM/DD/YYYY):

Marital Status: Choose Married Single

Occupation:

Social Security Number:

Prior Insurance

Company:

Expiration:

Dwelling Information

Monetary Value:

Number of Families:

Year Built:

Please check all that apply:

Owner/Tenant

Primary/Secondary

Slab/Crawl Space

Frame

Masonry

Brick

Combo

Number of Stories:

Living Area (square ft.):

Number of Baths:

Garage/Carport attached: Choose Yes No

Number of Cars:

Protective Devices:

Dead Bolts: Choose Yes No

Fire Extinguisher: Choose Yes No

Smoke Alarms: Choose Yes No

How many?

Central Alarm For:

Fire

Burglary

Sprinkler System: Choose Yes No

Business on Premises: Choose Yes No

Type:

Remarks: