Customer Homeowner Update Form

As a valued customer of Elliot Whittier, getting you the appropriate insurance coverage at the best possible pricing is paramount to what we do every day. Please help by taking a moment to complete the following, and return to us ASAP!

Regarding your home that you have insured with us:

* Required fields

First Name *

Last Name *

Street Address of insured property *

City *

State *

Zip Code *

Age of Roof *

Year of update to Electrical System *

#AMPS of electrical system *
60 Amps
100 Amps
200 Amps

Is the electrical system fuses or circuit breakers? *
Circuit Breakers
Fuses
Some of each

Year of Update to the Plumbing System *

Year of Update to the Heating System *

Is the Heating System... *
Gas
Oil
Other

Do Any Household Members Smoke? *
Yes
No

Do you or your spouse work less than 20 hours per week? *
yes
no

Enter your comments in the space provided below:

Email

Please contact me as soon as possible regarding this matter.

Call us at 1-800-696-3947
or
Email us at info@elliotwhittier.com

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