Ackerly Agency Inc. Please Fill out all the Information… Thank You! Ackerly Agency Inc. Your Email (required) Your Full Name (required) DOB(required) 2nd Name Insured 2nd DOB Effective Date(required) Current Carrier (required) Phone Number (required) Location Address (required) Construction Type (wood / mas.)(required) Wood FrameConcreteMetal Owner or tenant Occupied? (required) OwnerTenantVacant How Many Family?(required) 1234 Year built? required) # of Stories (required) Gas or Oil Heat? GasOil w/above Ground TankOil w/ Under Ground TankPropane Single Family or Townhouse? (required) SingleTownhouse Years at current residence?required) Miles to Fire Dept? (required) Feet to Hydrant? (required) Year of updates if home over 30 years old Wiring? Heating System Plumbing Roof Req. Dwelling Square Feet Req. Swimming Pool? Req. YesNo Trampoline? req. YesNo Pets? req. NoneDogsCats Wood burning Stove, Fireplace, Pellet Stove? Req. NoneWood StovePelletFireplace Smoke Detectors on all levels? Req. —Please choose an option—YesNo Fire Extinguisher? Req. —Please choose an option—NoYes Fire Sprinkler System? Req. —Please choose an option—NoYes Central Alarm? Req. NoneFireBurglarBoth Dead Bolt Locks on all Exterior doors? Req. —Please choose an option—YesNo Home Owner Association? Req. NoYes Have been cancelled in the last 3 years? Req. —Please choose an option—NoYes If yes Why? Have you had and lose reported to the company in the past 3 years even if no payout? —Please choose an option—NoYes If yes why?
