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Your Information
* First Name:
Middle Initial:
* Last Name:
* Street Address:
* City/Town:
State:	Georgia
* Zip Code:
Social Security Number: (Optional, but helpful)

Home Information
* Dwelling coverage limit:	$ Minimum of $25,000/maximum of $2,000,000.
* What year was your home built?	Year must be four digits (yyyy).
* Which construction feature best describes your residence?
* Smoke Detector/Fire Alarm System (select one) I have a smoke detector/fire alarm that is not connected to a central reporting station. I have a smoke detector/fire alarm that is connected to a central reporting station. I do not have a smoke detector or fire alarm system.
* Burglar Alarm (select one) I have a burglar alarm that is not connected to a central reporting station. I have a burglar alarm that is connected to a central reporting station. I do not have a burglar alarm.

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