# Bedrooms:		# Bathrooms:
# Fireplaces:		# Chimneys:
Special features (i.e., deck, air conditioning, alarm systems, pool, etc.)
Coverages:
Dwelling Cov. $		Contents $
Liability Cov. $		Deductible $ ($250, $500, $1,000, etc.)
Comments/Remarks (describe any scheduled jewelry, in-home business, or other special coverages needed here):
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