Name *


Address *


Home Phone *


Cell Phone *


DOB


Social Security Number


DO YOU HAVE INSURANCE NOW?
Yes
No

IF SO, WHO IS IT THROUGH?


WHEN DOES IT EXPIRE?


HOW MUCH ARE YOU INSURED FOR?


WHAT IS YOUR PREMIUM?


WHEN DID YOU MOVE IN?


WHAT YEAR WAS YOUR HOME BUILT?


IS IT:
Frame
Brick

IS IT:
VINYL SIDING
ALUMINUM SIDING

IS IT:
One Story
Tow Stories

SQUARE FOOTAGE OF EACH FLOOR


DOES IT HAVE A BASEMENT?
Yes
No

HOW MUCH OF IT IS FINISHED?


IS IT A WALKOUT?
Yes
No

ATTACHED OR DETACHED GARAGE?


NUMBER OF CARS?


ANY OTHER DETACHED STRUCTURES? (SHED, POLE BARN, GARAGE)


ANY DECKS, PORCHES, BALCONIES, OR BREEZEWAYS? (SQ. FT)


POOL OR HOT TUB?


DIVING BOARD?
Yes
No

IS POOL FENSED IN?
Yes
No

DO YOU HAVE DEADBOLT LOCKS?
Yes
No

DO YOU HAVE ATRIUM, PICTURE, BAY OR GREENHOUSE WINDOWS?


DO YOU HAVE SKYLIGHTS, SLIDING OR FRENCH DOORS?


DRYWALL OR PLASTER WALLS?
Drywall
Plaster

AMOUNT OF PAINT, WALLPAPER OR PANELING ON WALLS?


AMOUNT OF HARDWOOD, CARPET, TILE OR VINYL FLOORING?


NUMBER OF BATHROOMS?


DO YOU HAVE A JACUZZI TUB?
Yes
No

SEPERATE FR, LR, DEN, LAUNDRY ?


IS YOUR STOVE BUILT INTO YOU COUNTERTOP?
Yes
No

WHAT TYPE OF COUNTER?


DO YOU HAVE A BUILT IN MICROWAVE OR OVEN?


NUMBER OF FIREPLACES?


DO YOU HAVE A WOODBURNING STOVE?
Yes
No

DO YOU HAVE A WATER SOFTENER?
Yes
No

DO YOU HAVE CENTRAL AIR?
Yes
No

DO YOU HAVE A CARBON MONOXIDE DETECTOR?
Yes
No

DO YOU HAVE AN INTERIOR SPRINKLER SYSTEM, BURGLAR ALARM OR FIRE ALARM?


DO YOU HAVE ANY CEILING FANS?
Yes
No

ANY UPDATES TO ELECTRIC, PLUMBING, HEATING, ROOF (YEAR)?


HOW FAR AWAY FROM YOUR HOME IS THE NEAREST FIRE HYDRANT?


WHAT FIRE DEPARTMENT RESPONDS TO YOU?


YOUR HIGHEST LEVEL OF EDUCATION?


DOES YOUR SPOUSE WORK?
Yes
No

IF SO, WHERE?


ARE YOU SMOKERS OR NON-SMOKERS?
Smokers
Non

ANY PETS?


ANY CLAIMS FOR DOG BITES?
Yes
No

ANY CHILDREN?


THEIR AGES:


DO YOU HAVE A MORTGAGE?
Yes
No

IS YOUR INSURANCE ESCROWED?
Yes
No

ANY LOSSES TO YOUR HOME OR CLAIMS MADE IN THE LAST 5 YEARS?


DO YOU BELONG TO A CREDIT UNION, AARP, OR COLLEGE ALUMNI?


WHAT DEDUCTIBLE WOULD YOU LIKE?


ANY SECONDARY HOMES, RENTAL UNITS, WATERCRAFT, OR SCHEDULED JEWELRY?