*First Name
Middle Initial
*Last Name
Street Address
City
State
Zip
*E-mail
*Home Phone
Work Phone
Type of Home (Please Select) Single Family Dwelling Apartment Condominium Co-op Town House Twin Row Home
Date Purchased
Year Built
Square Feet
Number of Bedrooms
Number of Bathrooms
Square Feet of Basement
Basement Finished or Unfinished (Please Select) Finished Unfinished Check off each room that applies Living Room Dining Room Den Family/Recreation Room Kitchen Laundry Room Type of Construction (Please Select) Frame Masonry Masonry Veneer Aluminum Siding Plastic Siding Asbestos Siding
Type of Roof
Age of Roof
Number of Fireplaces
Number of Chimneys
Age of Heater
Number and type of underground storage tanks
Number and type of aboveground storage tanks
Has your Electrical system been updated or replaced? Yes No | Date Updated
Distance from home to fire hydrant (in feet)
Distance from home to fire station (in miles)
If rented, number of weeks rented per yearweeks per yr.
Your Current Home/Property Value and Insurance Coverage Limits
Current market value of your home
Current replacement cost (if not certain of replacement cost, estimate 85% of market value)
Dwelling coverage amount
Other structures coverage amount
Personal property
Medical payments
In the past five years, how many claims have been made on your home insurance policy?
Amount paid
Do you own pets? Yes No | If yes, type + breed
Do you own a Swimming Pool?? Yes No If yes, please check all that apply Above Ground Below Ground Fenced Diving Board
Do you own a trampoline? Yes No
Protective Devices Please check all that apply Burglar Alarm Central Station Monitored Fire Alarm Central Station Monitored
High Value Items Please list below any jewelry, precious stones, fine arts, antiques and furs, their purchase price and current appraised value.