Please tell us how you heard about
us:
Family
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Radio
T.V.
Letter
Post Card
Other
Name:
Date of birth:
Social Security Number:
Phone number:
Address of home needing insurance:
Years at that address: (if less
than 5, answer next 2 questions)
1
2
3
4
5+
Previous address:
Years at previous address:
Is this a new purchase? Yes
No
Length of time you have lived in
area:
Martial status: (if married,
answer next 6 questions)
Single
Married
Spouse's name:
Spouse's date of birth:
Spouse's social security number:
Spouse's employer:
Spouse's occupation:
Spouse's length of time at employer:
Your employer:
Occupation:
Length of time at employer:
Do you have current renter's or
homeowner's insurance? (if yes, answer next 3
questions) Yes
No
Current insurance company:
Years with company:
Policy number:
Have you had any claims in the last
five years? (if yes, answer next 3 questions) Yes
No
Date of claim:
Amount paid by insurance company:
Please give a brief description of
the claim:
Is your home currently under
construction? (if yes, answer next 3 questions) Yes
No
Start date of construction:
Expected finish date:
Is a general contractor building it?
(if yes, answer next question) Yes
No
Who is the contractor?
Year home was built:
# of stories:
Total square footage:
Are you within city limits? Yes
No
Is it built on a slope? Yes
No
What is the degree of the slope?
(not required)
Type of siding:
Construction of home:
Frame
Masonry
Mobile
Other
Type of foundation:
Continuous Concrete
Post/Pier
Slab
Crawl Space
Type of wiring: (required if home
was built before 1960)
Romanex/Copper
Knob and Tube
Do you have fuses or circuit
breakers? (required if home was built before
1960)
Type of roof:
Age of roof:
Garage style:
Attached
Detached
Carport
Built In
Do you have an automatic garage door
opener? Yes
No
Number of cars garage holds:
Is there a basement? (if yes,
answer next question) Yes
No
Is the basement finished? (if
yes, answer next question) Yes
No
Square footage of finished basement:
Is there a finished attic? (if
yes, answer next question) Yes
No
Square footage of finished attic:
Are there any detached structures?
(if yes, answer next 3 questions) Yes
No
Square footage of detached
Use of structure(s):
Year built:
Is there a porch? (if yes, answer
next question) Yes
No
Square footage of porch:
Is there a deck? (if yes, answer
next 2 questions) Yes
No
Square footage of deck:
Is it covered? Yes
No
Is there a breezeway? Yes
No
(The next set of
questions is required if your home is over 30 years
old)
Please list the year
each of the following items was last updated:
Wiring:
Plumbing:
Heating:
Electrical:
Exterior paint:
Number of full baths:
Number of 1/2 baths:
What is your primary heat source?
Is there a woodstove or a pellet
stove? (if yes, answer next 3 questions) Yes
No
Was it professionally installed? Yes
No
Is it an insert? Yes
No
Is it free standing? Yes
No
Number of fireplaces installed:
(if 1 or more, answer next 3 questions)
0
1
2
3+
Are there gas fireplaces? Yes
No
Are there wood fireplaces? Yes
No
Number of chimneys or hearths:
0
1
2
3+
Is it a prefabricated insert? (if
yes, answer next question) Yes
No
Type:
Propane
Natural Gas
Number of smoke alarms:
0
1
2
3
4
5+
Number of deadbolts:
0
1
2
3
4
5+
Number of fire extinguishers:
0
1
2
3
4
5+
Is there a central burglar or fire
alarm? Yes
No
Does your home have a working
sprinkler system? Yes
No
Are you within 1,000 feet of a fire
hydrant? Yes
No
How many miles are you from a fire
station?
Do you own dogs or exotic animals?
(if yes, answer next 2 questions) Yes
No
Please list the breed or type of
animal:
Has the animal ever bit anyone? Yes
No
Is there a business run on the
property? (if yes, answer next queston) Yes
No
Type of business:
Is this a rental property? Yes
No
Is there a homeowners association? Yes
No
Do you own a trampoline? Yes
No
Do you own a pool? Yes
No
Do you have a 6 foot privacy fence
around your property? (answer if you own a
trampoline or pool) Yes
No
For the following
questions, please list the number of built in items,
if any:
Dishwasher:
0
1
2
3
4
5+
Counter top stove:
0
1
2
3
4
5+
Electric air filter:
0
1
2
3
4
5+
Oven:
0
1
2
3
4
5+
Garbage disposal:
0
1
2
3
4
5+
Hot tub:
0
1
2
3
4
5+
Ceiling fans:
0
1
2
3
4
5+
Jetted tub:
0
1
2
3
4
5+
Micro hood:
0
1
2
3
4
5+
Range hood:
0
1
2
3
4
5+
Sauna:
0
1
2
3
4
5+
Carbon monoxide detector:
0
1
2
3
4
5+
Air conditioning:
0
1
2
3
4
5+
Intercom:
0
1
2
3
4
5+
Air humidifier:
0
1
2
3
4
5+
Central vacuum:
0
1
2
3
4
5+
Skylights:
0
1
2
3
4
5+
Please mark any items
you currently have or would like more information on:
Silverware
Furs
Other
If
other, please specify:
Would you like to include earthquake
insurance? Yes
No
If so, is your home bolted to the
foundation? Yes
No
Is your water heater strapped down? Yes
No
