Basic Information About You
Name (First and Last)
Address
City, Zip Code
Phone Number
Email Address
Information About Your Home
Construction
Frame
Brick
Stone
Mostly
frame with some brick or stone
Vinyl siding
Alumninum Siding
Mostly brick with
some siding
Year Built
Number of Families
Occupancy
Primary
Secondary
Seasonal
Building Type
1 story ranch
1.5 story (Capecod)
2 story
Bi-Level
Tri-Level
Protective Devices
None
Deadbolt lock
and smoke alarms
Central station fire
alarm
Central station
burglary alarm
Both
central station fire and burglary alarms
Do you have a Wood Stove?
Yes
No
Are you in a subdivision?
Yes
No
If yes, enter subdivision name:
Are you within the city limits?
Yes
No
Is there a basement?
Yes
No
If yes, enter % basement is finished:
0
25
50
75
100
Do you have a trampoline?
Yes
No
If yes, is it in a fenced in yard?
Yes
No
Do you have a pool?
Yes
No
If yes, is it fenced in?
Yes
No
Do you have dogs or exotic pets?
Yes
No
If yes, enter the type of pet:
Miles to Fire Department
5 miles or less
More than 5 miles
Feet to Hydrant
1,000 feet or less
More than 1,000 feet
Updates
Age of roof
Age of furnace
Year of plumbing updates
Year of electrical updates
Coverage Information
Dwelling Amount ($)
Liability Limit
25,000
50,000
100,000
200,000
300,000
500,000
Medical Payments
500
1,000
2,000
5,000
Deductible
50
100
250
500
1,000
2,500
5,000
Earthquake
Yes
No
Mine Subsidence
Additional Questions
Do you have a boat(s)?
Yes
No
If yes, please specify year, make, model, HP, and max speed for each boat:
Do you have one or more jet skis?
Yes
No
If yes, please specify year, make, model, CC's and length:
Do you have one or more recreational vehicles?
Yes
No
If yes, please specify year, make, model, and engine size:
Do you have specialty items needing unique coverage or value?
Yes
No
Note: These items generally need appraisals for accurate coverage. If yes, please specify brief description and value:
