Name                       Required

E-mail address       Required 

Address                   

City                         Required

State                     Massachusetts Residents Only

Phone                        Fax     

Amount of Contents Insurance    20,000 25,000 30,000 40,000 50,000

Amount of Liability Insurance      500,000 300,000 1,000,000

Replacement cost contents         yes   no

Your apartment is in a      2 to 4 family house over 4 family apt building

                                   Comments

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