Yr. of Construction:

i.e. 1995

Roof Material:

-Select-CompositionWoodTileOther

Approx House Sq Ft:

i.e. 2,000

Type of Home:

-Select-Single Fam.DuplexCondoOther

Outside Walls:

-Select-BrickWoodStuccoOther

Inside City Limits?

-Select-YesNo

Household:

-Select-SmokingNonsmoking

Age of Owner:

Fire Extinguisher?

-Select-YesNo

Dead Bolt Locks?

-Select-YesNo

Smoke Detector?

-Select-YesNo

Approx loan amount?

    (i.e. $100,000)

Fireplace?

-Select-YesNo

Swimming Pool?

-Select-YesNo

Monitored Alarm(s)?

-Select-YesNo

Satellite Dish/Antenna?

-Select-YesNo

Garage Size:

-Select-1 car2 car3 carCarport

# of Stories:

-Select-11.523+

# of Bathrooms:

-Select-1234+

Age of Roof:

Years

If "yes" for a Satellite Dish/Antenna, please list the value:    (i.e. $2,000)

Amount of coverage requested?    (i.e. $100,000)

Home currently insured with?    ("New" = new home)

Have you had any claims within the past three (3) years? If so, please list below.

Comments...(up to 70 characters will show)