GENERAL INFORMATION

Name   Address

Daytime Phone   Evening

E-Mail Address   FAX

Is this a first time purchase? No Yes   Have you filed a claim on any 

property in the last 3 years? No Yes  State date of loss and 

description of loss. 
                                         

HOMEOWNERS

Square Feet   Number of Stories 1 1 1/2 2 Bi-Lev/RSD Ranch Split Level T/H Center Unit T/H End Unit

Central Air Conditioning No Yes   Garage None Carport 1 Car Garage Attached 2 Car Garage Attached 3 Car Garage Attached 1 Car Garage Built In 2 Car Garage Built In 3 Car Garage Built In

Number of Fireplaces   Year House Built   Deck No Yes

Number of Bathrooms   Age of Insured   Age of Roof

Roof Type Asphalt Shingle Wood Shingle Wood Shake Synthetic Shingle/Tile Spanish Tile Concrete/Cement-Fiber Tile Slate Rock (Tar & Gravel)   Porch No Open Screened

Interior Drywall/Sheetrock Plaster   Breezeway No Open Screened

Exterior Material Stucco on Frame Wood Siding Stone Veneer Solid Stone Paint on Masonry Alum/Vinyl Siding Asbestos Shingles Stucco on Masonry Brick Veneer Solid Brick Wood Shakes Adobe   Number of Skylights  

Stained Glass No Yes   Greenhouses No Yes   Sauna No Yes

Ornamental Stairs No Yes   Laundry Tub No Yes   

Additional Furnace No Yes   Intercom System No Yes

Screened Pool Enclosure No Yes   Burglar Alarm No Yes

Electric Air Cleaner No Yes   Indoor Barbecue No Yes

Trash Compactor No Yes   Solar Panels No Yes

Spiral Staircase No Yes   Fire Sprinklers No Yes   

Central Vacuum No Yes   Shower Stall No Yes

Smoke Detector No Yes   Fire Extinguisher No Yes

Dead Bolt Locks on all doors including all sliders No Yes  

Number of Skylights   Number of Garage Door Openers

Number of Wet Bars   Number of Exterior Shutters

Number of Interior Shutters   Number of Jacuzzi/Hottubs

Floater Jewelry Fine Arts Furs Silverware Guns   Value $

Would you like the quote mailed, e-mailed, faxed, or by personal 

contact.

Additional Information

CONDOMINIUM AND RENTERS 

Square Feet   Number of units under the same roof

Amount of contents $ Age of Insured   Building Age

Smoke Detector No Yes   Fire Extinguisher No Yes

Dead Bolt Locks on all doors including all sliders No Yes

Floaters Jewelry Fine Arts Furs Silverware Guns   Value $  

Would you like the quote delivered by Personal Contact Mail E-Mail Fax

Additional Information