Clearwater Underwriters, Inc.

Insured's Name: (*)

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Agency Name: (*)

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Contact Name:

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Agent Email Address: (*)

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Policy Type: (*)

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Expiring Policy #: (*)

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Effective Date: (*)

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Have there been any additions built onto the home:

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If yes, # of square feet added:

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Has the roof been replaced in the last year:

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If yes, roof material:

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If roof was replaced, what date:

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Please list any changes you would like to make to this policy:

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Renewal Questionnaire