| Applicant Name: | |
| A you an Owner, Resident or Both: | |
| What is your Date of Birth: | (mm/dd/yyyy) |
| What is Your Social Security Number: | |
| Property Street Address: | |
| Property City: | |
| Property State: | |
| Property Zip Code: | |
| Dwelling Description: | |
| If Other, please describe: |
|
| Year Constructed: | |
| Year Renovated (If Applicable): | |
| Square Feet: | |
| Total Number of Rooms: | |
| Age of Roof: | |
| Is there a Basement? | |
| If Yes, is it Finished or Unfinished? | |
| Number of Families: | |
| Number of Stories: | |
| Number of Baths: | |
| Is there a Pool? | |
| If Yes, is it Inground or Aboveground? | |
| Is it Fenced in? | |
| Number of Chimneys: | |
| Is there a Deck? | |
| If Yes, what is the square footage: | |
| Is there a Porch? | |
| If Yes, what is the square footage: | |
| Is there a Garage? | |
| If Yes, where is it located: | |
| Number of Cars: | |
| Type of Heat: | |
| If Oil, where is the location of the tank: | |
| Is there a Fireplace? | |
| Is there a Woodstove: | |
| If systems have been updated, please give year: |
| (leave blank if no updates since date of construction) |
| Electrical | |
| Plumbing | |
| Other | |
| Is there an alarm system? | |
| If Yes, please describe: | |
| Are there any deadbolts on doors? | |
| If Yes, where? | |
| Is there a Fire Extinguisher on premises? | |
| Distance to public water hydrant: | |
| Distance to Fire Station: | |
| Replacement Value of Dwelling: | |
| Market Value of Dwelling: | |
| Are there any other Structures on Premises? | |
| If Yes, please describe: | |
| Any business use in home? | |
| If Yes, please describe: | |
| Personal Property Value (contents in home): | $ |
Are there Valuable Items requiring additional
coverage (i.e jewelry, art, collectibles)? | |
| If Yes, please describe: | |
| Are there any dogs on property? | |
| If Yes, how many? | |
| If Yes, what breeds? | |
| Have you filed any claims in the past 3 years? | |
| If Yes, please describe: | |
| Have you ever filed for Bankruptcy? | |
Please Enter Your Contact Information:
|
| Your Name: | |
| Address: | |
| City: | |
| State: | |
| Zip Code: | |
| E-mail Address: | |
| Home Phone: | |
| Work Phone: | |
|
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