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General Information

Name: Address: City:   State:   ZIP: County:   Email: Phone Day:   Best time to call:     Morning  Afternoon Occupation: How long at current job:     years   months

 

Current Homeowners Policy Information:

Company Name: Policy Exp. Date: / / Amount Insured For: $      Premium: $ Term: 6 Months   1 Year   Other   Current Liability Limit: $300,000$500,000$1,000,000 Any Other Residence Owned or Rented? Yes   No                   Homeowners Claims: Date Type Amount Paid $ $ $

 

Home Information

How long at present address: years months # of claims in last 3 years:         Sq. footage of home (excluding garage and basement): Year home was built:         Distance to nearest fire hydrant in feet: Feet Distance to responding fire department in miles: Mile(s)

 

Structure Information

Type: Construction: Roof: Foundation: Garage: 1 Story1 1/2 Story 2 StorySplit Level Bi-LevelOther Frame or StuccoMasonry or Veneer Masonry Other Asphalt Shingle Wood ShingleTile or Slate Other BasementCrawl Space SlabOther 1 Car2 Car3 Car4 CarNone AttachedDetachedBasement Built-in Car PortNone   Age of roof:   yrs.

 

Features

Bathrooms: Basement: Deck/Porch/Patio: Fireplaces:   # of Full:     # of Half:   NoneFinishedUnfinished Sq. Ft: Deck Sq. Ft:   Porch Sq. Ft:     Screened Patio Sq. Ft:    # of Chimneys:    # of Hearths:

 

Additional Features

Heating System: Central Air: Central Vac: Security Alarm: Fire Alarm: Smoke Detector: NoneElectricGasOil PropaneSolarOther yes no  yes no  NoneMonitoredNot Monitored NoneMonitoredNot Monitored yes no

 

Specialty (Scheduled) Items

Jewelry: Furs: Computers: Please fill in OTHER name (if any) $ $   AMOUNT   $ $ $

 

Additional Comments:

Please give any additional comments about the coverage you desire: