Name:


Physical Address:


City:


State:

Zip Code:




Mailing Address:


City:


State:

Zip Code:




Home Phone:

Work Phone:


E-mail (required):


Social Security Number:

Many of the companies we represent require a credit check prior to quoting.

Have you had continuous coverage for at least 12 months?

Yes

No

If not, why not?


Present Insurance Company:


Present Coverage Amount:


Renewal Date:


Occupation:


Claims in Last 3 Years:

0   1   2   3   4+

Alarm System:

Local burglar

Central Station fire

Direct burglar

Direct fire

In what year was your home built?


Type?

1-family

2-family

3-family

What style is your home?

1 story

1.5 story

2 story

2.5 story

Bi-level

Split level

Other:

What is the total square footage of the finished living area of your home?
square feet

Does your home have a:

Deck
(Sq. Ft.: )

Cathedral ceilings
(% of home: % )

Breezeway
(Sq. Ft.: )
     Is Breezeway:

     Enclosed

     Screened

     Open

Porch
(Sq. Ft.: )
     Is Porch:

     Enclosed

     Screened

     Open

Which of the following additional features are in your home?

Skylights:
#

Bay Windows:
#

Bow Windows:
#

Picture Windows:
#

Glass Sliding Doors:
#

Atrium Windows:
#

Atriums/French Doors:
#

Woodstoves:
#

Greenhouse:
Sq. Ft.

Central Alarm:
%

Hot Tub:
Sq. Ft.

Wet Bars:
#

Do you have a garage?

No

Yes:

      Attached

      Built-in

      Carport

      Detached

      How many vehicles can be parked in the garage?

      One car

      Two cars

      Three cars

      Four cars

Does your home have a basement?

No

Yes: % finished %

If your home does not have a full basement, what percentage is:

Slab:
%

Crawl space:
%

Stilts:
%

Which materials listed below best describe the materials found in your home? Please indicate the materials as percentages of total (e.g. 5%, 10%, 15%, etc.). If your home contains materials not found on this list, please select a similar material that is in the list and use the last section of this form for additional explanation, if necessary. Your selection should total 100% in each category.

How many kitchens are in your home?


Please indicate if any of your kitchens have the following features:

     Corian, granite, or authentic marble countertop

     Center island w/ cabinets or sink

     Jenn-aire stove

     Walk-in freezer

     Sub-zero refrigerator

     Motorized pantry

     Indoor BBQ

Please indicate the number of bathrooms that are:

Full (3 or more fixtures w/ tub)

Half (sink, toilet, stand up shower)

Half (sink/toilet only)

Please indicate quality grade:

Standard

Custom

Designer

What is your home's primary source of heat?

Oil

Gas

Electric

Other:

If you heat with oil, where is the storage tank located?

Basement

Outside - above ground

Garage

Outside - underground

Other:

Do you have a secondary source of heat?

No

Yes (please describe):

Does your home have central air conditioning?

No

Yes

     If yes, shared ducts with heating system?

     No

     Yes

Does your home have a central vaccuum system?

No

Yes

Do you have pets?

No

Yes (kind/breed):

Do you have a pool?

No

Yes

     If yes, what kind?

     Inground

     Above ground

     Fenced

Do you have a trampoline?

No

Yes

How many fireplaces with masonry chimneys does your home have? Double is two fireboxes and one chimney. Triple is three fireboxes and one chimney.

None

Single (# )

Double (# )

Triple (# )

Additional information: