Name   
Address
Social Security Number: 

Home Phone:  Call Here First
Work Phone   Call Here First

Information About Your Home

Year Built  Square Ft Number of Stories
Miles to Fire Dept.    Number Feet to Hydrant
Construction Type:  Frame   Brick   Veneer Siding

Garage?  Attached   Detached   # of Cars
Any other Structures on premises:  Yes      No    
                                                      Type: 

Baths:  Number Full Baths   Number of Half Baths
Fireplace ?  Yes    No   If Yes, Number of Hearths
Basement:  Yes  No   If finished, % finished: 
Central Air:  Yes   No        Swimming Pool:  Yes  No
Porch or Deck?  Yes No   Square footage Deck/Porch
Trampoline?  Yes   No    Wood burning Stove?  Yes No

Safety Features:  Dead Bolt Locks  -  Yes   No 
                          Smoke Alarms      -  Yes   No 
                          Fire Extinguishers  -  Yes   No 
                      Central Station Alarm - Yes   No 

Home Updates:   Heating Type: 
                       Age of Furnace :   
       Age of Roof:      Roof Material: 
Year Electrical Updated:    Circuit Breakers:  Yes   No 
 Amps (electrical service):  60 amps   100 amps     200 amps
List Plumbing Updates, if any: 

List any built-in features, such as dishwasher, garbage disposal, hot tub, whirlpool baths, etc., that increase value to your home
           

List any pets, type and breed:  

Estimated Lot Value: 
Estimated Market Value of Home: 

Prior Homeowners Insurance Company: 

List all claims made in past 3 years (Indicate date and brief description of loss): 

NOTE:  

If you desire to schedule personal property such as jewelry, furs, fine arts, collectables, etc., please call us at 784-9090 or toll free at 800-242-9090.  Many items will require a current appraisal. 

All quotes are subject to a favorable credit report as required by the issuing insurance company.