Reshop Intake TEST - GG Insurance

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Arkansas Insurance Agency

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Name(Required)

First and Last Name

Phone Number(Required)

What's the best number to reach you at?

Email Address(Required)

What is the best email address to have on file for you?

Policies to Review(Required)

Home

Auto

Other

Check all that apply!

Is there a pool on the premises?

No

Yes

Is it enclosed (fenced)?

No

Yes

Is there a removable diving board and/or slide?

No

Yes

Do you have any children?

No

Yes

What is the age of your roof?

Have there been any updates to the home?

For example, added square footage, remodeled kitchen and/or bathrooms, etc.