Your Name:

Property Address:

Zip Code:

Email Address:

Phone Number:

Current Age:

Anyone smoke?

Yes

No

Are you a first-time homebuyer?

Amount of Mortgage:

If no, how long at this address:

Yes

No

Do you have insurance now?

Present insurance company:

My policy expires:

Yes

No

Have you reported any property claims within the past 3 years?

If yes, please give claim details here:

Yes

No

Number of Units:

Building:

Garage:

Roof Type:

Is the home equipped with at least one working smoke alarm?

Yes

No

Year Built:

Do all exterior doors have dead-bolt type locks?

Living Area Square Feet:

Yes

No

Does your home  have at least one fire extinguisher 2 1/2 pound or larger?

Yes

No

Is there a central station monitored burglar alarm system?

Yes

No

Exterior Walls:
enter percent of each as it applies to your home

Home Enhancements
check the box if your home has any of the following items

Interior Walls
check one

Cooling and Heating
check all that apply

Drywall

Forced Air Conditioning and Heating

Stucco on Frame

Burglar Alarm

Plaster

Swamp Cooler

Fireplace

Stucco on Masonry

Wall Heater with thermostat

Swimming Pool

Paint on Masonry

Wall Heater without thermostat

Central Vacuum

Wood Stove

Wood Siding

Trash Compactor

Solar Panels

Number of Bathrooms

Other Home Enhancements:
list the quantity of each item if your home has any of the following

Aluminum Siding

Intercom System

Wood Shakes

Electric Air Cleaner

Brick Veneer

Sauna

Garage Door Opener

Stained Glass Windows

Stone Veneer

Skylights

Additional Air Conditioner

Solid Brick

Jacuzzi/Hot-tub

Total must equal 100%

Wet bar

Deductible

Replacement Cost of your Contents

Replacement Cost of your Home

Mortgage Protection

Home Warranty Protection

Other Coverage Requested