Homeowners Prefer to fill out by hand? Download PDF Step 1 of 2 50% Insured Name SS Number Today's Date Month Day Year Number in HouseholdMarital Status Single Married Date of Birth Month Day Year Email Home PhoneCell PhoneOccupation Employer Number of YearsCo-Insured Name SS Number Date of Birth Month Day Year Occupation Employer Number of YearsProperty Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Previous address if less than 3 years Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Untitled Single Family Duplex Triplex Condo Townhouse Owner or tenant occupied? Owner Occupied Tenant Occupied Estimate closing date/Exp date Purchase PriceLoan AmountCurrent/Desired Dwelling Coverage LimitDeductiblesLiability Coverage AmountMedical Payment Amount Home: Current PremiumCurrent Policy Number Years with prior carrierPrior Insurance Carrier Current Policy Expiration Flood: Current PremiumCurrent Policy Number Years with prior carrierFlood zone Current Policy Expiration Losses or claims in the past three years on any homes owned? Yes No Type of loss Amount Paid: $Date Month Day Year Dwelling InformationYear BuiltLiving Square FeetNumber of StoriesAny part of home over water? Yes No What part/Square feet? Story unit is on How many units in building? Has home been renovated to studs including new windows and doors? Yes No What year? Type of foundation Slab Piers Open or closed foundation between piers? Open Closed Pier Height Roof type Shingle Metal Other Roof Shape Flat Gable Hip Year roof was updated Shingle Type Architectural 3-tab Water heater update year AC/Heating update year Wiring update year Plumbing update year Type of A/C & Heating Central Unit Window Unit Gas Electric Number of A/C UnitsPlumbing type Copper Polybutylene Galvanized PEX installed prior to 2006 PEX installed post-2006 Number of BedroomsNumber of BathroomsNumber of FireplacesType of Fireplace Gas Burning Wood Burning Number of carsCarport? Yes No Garage? Yes No Type of garage/carport Attached Unattached Flooring type (check one or multiple) Wood Carpet Ceramic Tile Vinyl Other % Wood% Carpet% Ceramic Tile% Vinyl% OtherSpecify Other Exterior Wood Stucco Brick Veneer Vinyl Other % Wood% Stucco% Brick Veneer% Vinyl% OtherSpecify Other Any interior items that may add value? (Elevator, Wet Bar, Whirlpool Tub, Sky Lights, Bay Windows, Interior French Doors)Porches/Patios under roofline? Yes No Open/Screened? Open Screened Square footage of porchPatio/Decks NOT under roof line? Yes No Attached to home? Yes No Open/Screened? Open Screened Square footage of porchUnattached structures (sheds, barns, fences, etc.) on property? Unattached Structure Value Distance to fire hydrant Miles to fire station Swimming pool? Yes, in ground Yes, above ground No Diving board? Yes No 4 ft fence w/ locking gate? Yes No Slide? Yes No Burglar Alarm Monitored Unmonitored Fire Alarm Monitored Unmonitored Fire Extinguishers? Yes No Deadbolts on all exterior doors? Yes No Gated Subdivision? Yes No Trampoline? Yes No Hot tub on premises? Yes No Smokers in household? Yes No Pets? Yes No Breed? Bite History? Yes No By signing below, I certify that the information above is true.PhoneThis field is for validation purposes and should be left unchanged. Δ
