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Contact Information
First Name*
Last Name*
Address*
City*
State/Prov.*
Zip/Postal Code*
Country*
Phone*
 Ext  		Fax
Email
Web
http://
 
Social Security Number
 
Have you had continuous coverage for at least 12 months?
 Yes
 No
 
If not, why not?
 
Present insurance company
 
Present coverage amount
 
Renewal date
 
Claims in the last 3 years
 1
 2
 3
 4+
 
Water claims in the last 5 years
 1
 2
 3
 
Square footage of living space
 
Year home was built
 
Deductible
 $250
 $500
 $1000
 $2500
 
Liability
 $100,000
 $300,000
 $500,000
 
Lot
 Level
 Sloped
 
If sloped how many degrees?
 
House type
 1 story
 1 1/2 story
 2 story
 Split level
 Bi-level
 
Construction
 Frame or Stucco
 Masonry Veneer
 Masonry
 
Foundation
 Basement
 Crawl Space
 Slab
 
Roof
 Asphalt Shingle
 Wood Shingle
 Tile or Slate
 Other
 
Age of roof
 
Garage
 1 car
 2 car
 3 car
 4 car
 
Garage Type
 Attached
 Detached
 Basement
 Built-In
 Car Port
 
# of Full Bathrooms
 1
 2
 3
 4
 5
 
# of Half Baths
 1
 2
 3
 4
 5
 
Bedrooms
 1
 2
 3
 4
 5
 
Other Features
 Central Air Conditioning
 Central Heating
 Central Vaccum
 Security System
 Wet Bar
 Whirlpool Tub
 
Fireplaces
 1
 2
 3
 4
 5
 
Woodstoves
 1
 2
 3
 4
 5
 
Basement
 
Finished
 Yes
 No
 
Sq. Feet
 
Deck, Porch, Patio
 
Deck sq. foot
 
Porch sq. foot
 
Screened Patio sq. foot
 
Enclosed Porch sq. foot
 
Acreage:
 Less than 5
 More than 5
 
Fire Hyudrant
 Less than 1000 ft
 More than 1000 ft
 
Miles from Fire Department
 
Other
 Smoke detector
 Fire extinguisher
 Deadbolts
 
Any animals: (if so describe breed & # of animals)
 
Swimming Pool
 Yes
 No
 
Is it fenced?
 Yes
 No
 
Any ponds?
 Yes
 No
 
Any trampolines on property?
 Yes
 No
 
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