Applicant Name
*
First Name
Last Name
Date of Birth
MM
DD
YYYY
Contact Number
(###)
###
####
Email
*
Location Address
County
Type of Property
Previous Address (If Recently Moved)
City or County Limits?
Year Built
Approximate Value of Dwelling (Not Including Land)
Finished Living Space Square Footage (not including attics and basements
Is property situated on more than 5 acres?
Distance to Fire Hydrant (in feet)
Distance to Fire Station (in miles)
Fire Station on Call
Insurance Company Name
Insured Amount
Current Deductible
Current Liability Limit
Policy Number
Effective Dates
Requested Limits for Quote
Same as current? If no, please enter requested deductible and liability limits.
Exterior
Number of Stories (Not Including Attics or Basements)
Foundation
Number of Garages
Attached or Detached Garage?
Type of construction:
How many cars will it hold?
Carport?
Number of Decks/Balconies and SF
Number of Open Porches and SF
Number of Sunroom/Screened-in Porches and SF
Number of Breezeways and SF
If any of the above are enclosed, *If any are enclosed, what type foundation do they have?
What year was the roof installed?
Type of shingle:
If other, please add type of shingle
A/C?
Heat Type:
Supplemental Heating?
Are heat and A/C run through the same ducts?
Number of Fireplaces
Number of Chimneys
Are fireplaces gas or woodburning?
Home Safety Features
Number of Full and Half Baths:
Number of Bedrooms:
Number of Kitchens:
Flooring Materials
If other, please specify type.
Enter approximate percentages of each flooring type:
Wall coverings
If other, please specify type.
Enter approximate percentages of each wall covering type:
Ceiling Materials
If other, please specify type.
Enter approximate percentages of each ceiling type:
Check any other features of your home:
If other, please specify
Pool: above or in-ground
Pool: Fenced In?
Pool: Approximate Size
Please list any improvements, and their approximate dates, made to your home, such as new roofing, plumbing, heating, electrical, etc.
Please list any detached structures located on the property, such as a shed, stable, barn, etc.
Please list any scheduled personal property that should be included such as jewelry, fine arts, silver, and/or guns and their value.
If you have had any property losses in the last 5 years, please give details and claim totals (if possible).
Additional Notes: