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G GONZALEZ AGENCY
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G
GONZALEZ
AGENCY
Home Proposal Request
*
First name
*
Last name
*
Email
*
Phone
Preferred contact method
Email
Text
Call
Preferred time to contact
Morning
Lunch
Afternoon
Specified time
*
Date of Birth
Month
Month
Day
Year
Primary Address
*
Country/Region
*
Address
Address - line 2
*
City
*
Zip / Postal code
Type of Coverage
Homeowner
Renters
Condo
Other
*
Current Insurance?
Yes
No
New Purchase
Roof Year
# of Fireplace(s)
Pool
# of Beds
# of Baths
Trampoline
*
Desired Deductible
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