Mehaffey Financial Service - Homeowners Insurance : Quote Request

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Mehaffey Financial Service
Bookkeeping Tax Solutions, LLC
484 Field Avenue
Fieldale, VA 24089
(Located in Martinsville & Henry County, Virginia
next to the Fieldale Fire Station)

George Mehaffey, Jr., LUTCF
Office Phone: 276-681-6848
Email address: geo@mehaffeyfinancial.com

David Mehaffey, CPA/PFS, CTP
Office Phone: 804-441-2970
Email address: dmehaffey@cpa.com
1604 Meadowview Lane
Martinsville, VA 24112


» Name:
Address:
City:
State:
Zip:
» Home Phone:
Work Phone:
» Email:
Age:

Insurance Type:	Single Family Townhouse Condo Renters
If multi-family bldg, how many residential units:	1-4 5-12 12+
Construction Type:	Frame Masonry Masonry Veneer
Year Built:
Nearest Fire Hydrant:	under 1000 feet none
Nearest Fire Department:	1 2 3 4 5 5+ miles
Smoke Detector:	Yes No
Deadbolt Locks:	Yes No
Fire Extinguisher:	Yes No
Central Station Fire Alarm:	Yes No
Central Station Burglar Alarm	Yes No
Swimming Pool:	Yes No
If yes, is it fenced in:	Yes No
Wood Burning Stove:	Yes No
Do you have a dog:	Yes No
Market Value $:
Existing dwelling coverage amount $:
Desired Coverage Amount $:
Liability Limit $:
Deductible:	250 500 1000
Any special coverages:
Current Insurance Company:
Expiration date (or settlement if new purchase):
Any claims past 5 years:
Please use the space below to add comments regarding any special circumstances.