Potwora Agency West provides our family with friendly fast customer service.
I will be using them for years to come.
Linda B
Name
County
Address
City
Zip Code
1. Policy canceled, declined or refused? Yes No
2. Any previous losses?
3. Any arrest for any reason?
4.Been requried to file evedence of financial responsiblity? Yes No
Distance from nearest fire hydrant? (Ft)
Distance from nearest fire department (mi)
Smoke detectors? Yes No
Type Battery operated 1 Hardwired 2 Central Station 3 Local 3
Do you desire sewer & water backup coverage No Yes
Do you have any personal items such as jewelry, furs, guns, silverware, coin or stamp collections which may be valued at cost of $1000 or greater or which you may desire coverage other than fire or theft?
