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Primary Insured's Occupation:
Date of Birth
MM slash DD slash YYYY
Dwelling Information
Year Home Built:
Home Square footage:
Is this Builder's Risk? (new home constr.)
Is this Builder's Risk? (new home constr.)
Yes
No
Month/Year home to be complete:
Number of units:
Type foundation:
Basement
Slab
Crawlspace over slab
Other (list in remarks)
What % is finished
Type Construction:
Frame
Brick/Veneer
Stone
Other (list in remarks)
Type Roof:
Shingle
Wood Shake
Tar/Gravel
Spanish Tile
Metal
Other
Number of stories:
1
1.5
2
3
Do you own animals or pets?
Do you own animals or pets?
Yes
No
If yes, list type/for dogs, list breed:
Are You Near Brush Area?
# of feet to nearest fire hydrant:
# of miles to nearest fire station:
Does home have a garage?
Does home have a garage?
Yes
No
Tell whether built in, detached/attached, and how many cars?
Currently Insured?
Currently Insured?
Yes
No
Name of Carrier & how long insured?
Prior Claims?
Prior Claims?
Yes
No
Describe claims in detail:
Rate Your Credit History and Past Insurance Payment History: (Some companies products are based on your credit and payment history
Excellent
Fair
Poor
Horrible
Plumbing type:
Copper
Galvanized
Mixed
Heating Type:
Gas (propane or natural)
Electric
Oil (if oil, list tank location in remarks)
Circuit Breakers/Fuses?
# Bedrooms:
# Bathrooms:
# Fireplaces:
# Fireplaces:
Special features (i.e., deck, air conditioning, alarm systems, pool, etc.)
Coverages
Dwelling Cov. $
Contents $
Liability Cov. $
Deductible $ ($250, $500, $1,000, etc.)
Comments/Remarks (describe any scheduled jewelry, in-home business, oil tank location, or other special coverages/remarks here):
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