Postal Code:
Fax#:
E-mail:
Current Homeowner Coverages
Property Coverage Deductable: 250 300 500 10002500
Comprehensive Liability Amount: 500,0001,000,0002,000,000
Medical Payments: 1,000 2,0003,000
Guaranteed Replacement Cost Coverage: Yes No
Water Backup Coverage: Yes No
Earthquake Coverage: YesNo
If mixed, specify percentage of construction that is Siding % specify percentage of construction that is Brick Veneer % (total must equal 100%) specify percentage of construction that is Solid Masonary %
Type of house:Single Family Townhouse Townhouse end of group Duplex
Type of Alarm:Smoke Detector Local Burglar Local Burglar and Fire Monitored Burglar Monitored Burglar and Fire None
Sprinklers: No Yes
Year house built: If older than 25 years, indicate year of updates for: Electrical Plumbing Heating Roof
Ground Floor Square Footage:
Shape of house (number of corners):4 5-7 8-11 12 plus 3 Wall addition (square feet): Total basement area (square feet): Percentage of baesment finished: Attached Garage:None1 car 2 car 1 carport2 carport Garage Door Opener Yes No Family Room: Yes No Sun Room: Yes No Den: Yes No Seperate Dining Room: Yes No Number of Bathrooms:1 1 1/2 2 2 1/23 Number of Fireplaces:None 1 2 3 Any hardwood floors: Yes No Central Air Conditioning: Yes No Decks (total square feet): Porches (total square feet): Large laundry room: Yes No Large Foyer: Yes No Central Vac: Yes No Video Entry System: Yes No Sauna: Yes No Hot Tub: Yes No Jaquzzi Bath: Yes No Dishwasher: Yes No Trash Compacter: Yes No Range Hood: Yes No Garbage Disposal: Yes No Is your house within 1000 ft of a fire hydrant? Yes No If not, how far is your house from a fire hall? km Have you had any claims in the past five years? Yes No If Yes, please give details: Any additional information that you might feel is important in quoting your home insurance:
3 Wall addition (square feet):
Total basement area (square feet):
Percentage of baesment finished:
Attached Garage:None1 car 2 car 1 carport2 carport
Garage Door Opener Yes No
Family Room: Yes No
Sun Room: Yes No
Den: Yes No
Seperate Dining Room: Yes No
Number of Bathrooms:1 1 1/2 2 2 1/23
Number of Fireplaces:None 1 2 3
Any hardwood floors: Yes No
Central Air Conditioning: Yes No
Decks (total square feet):
Porches (total square feet):
Large laundry room: Yes No
Large Foyer: Yes No
Central Vac: Yes No
Video Entry System: Yes No
Sauna: Yes No
Hot Tub: Yes No
Jaquzzi Bath: Yes No
Dishwasher: Yes No
Trash Compacter: Yes No
Range Hood: Yes No
Garbage Disposal: Yes No
Is your house within 1000 ft of a fire hydrant? Yes No
If not, how far is your house from a fire hall? km
Have you had any claims in the past five years? Yes No
If Yes, please give details:
Any additional information that you might feel is important in quoting your home insurance: