Homeowners Prefer to fill out by hand? Click here to download a printable version Step 1 of 2 50% Insured NameSS NumberToday's Date MM DD YYYY Number in HouseholdMarital StatusSingleMarriedDate of Birth MM DD YYYY Email Home PhoneCell PhoneOccupationEmployerNumber of YearsCo-Insured NameSS NumberDate of Birth MM DD YYYY OccupationEmployerNumber 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 UntitledSingle FamilyDuplexTriplexCondoTownhouseOwner or tenant occupied?Owner OccupiedTenant Occupied Estimate closing date/Exp datePurchase PriceLoan AmountCurrent/Desired Dwelling Coverage LimitDeductiblesLiability Coverage AmountMedical Payment Amount Home: Current PremiumCurrent Policy NumberYears with prior carrierPrior Insurance Carrier Flood: Current PremiumCurrent Policy NumberYears with prior carrierFlood zoneLosses or claims in the past three years on any homes owned?YesNoType of lossAmount Paid: $Date MM DD YYYY Dwelling InformationYear BuiltLiving Square FeetNumber of StoriesAny part of home over water?YesNoWhat part/Square feet?Story unit is onHow many units in building?Has home been renovated to studs including new windows and doors?YesNoWhat year?Type of foundationSlabPiersOpen or closed foundation between piers?OpenClosedPier HeightRoof typeShingleMetalRoof ShapeFlatGableHipYear roof was updatedShingle TypeArchitectural3-tabWater heater update yearAC/Heating update yearWiring update yearPlumbing update yearType of A/C & HeatingCentral UnitWindow UnitGasElectricNumber of A/C UnitsPlumbing typeCopperPolybutyleneGalvanizedPEX installed prior to 2006PEX installed post-2006Number of BedroomsNumber of BathroomsNumber of FireplacesType of FireplaceGas BurningWood BurningNumber of carsCarport?YesNoGarage?YesNoType of garage/carportAttachedUnattachedFlooring type (check one or multiple) Wood Carpet Ceramic Tile Vinyl Other % Wood% Carpet% Ceramic Tile% Vinyl% OtherSpecify OtherExterior Wood Stucco Brick Veneer Vinyl Other % Wood% Stucco% Brick Veneer% Vinyl% OtherSpecify OtherAny interior items that may add value? (Elevator, Wet Bar, Whirlpool Tub, Sky Lights, Bay Windows, Interior French Doors)Porches/Patios under roofline?YesNoOpen/Screened?OpenScreenedSquare footage of porchPatio/Decks NOT under roof line?YesNoAttached to home?YesNoOpen/Screened?OpenScreenedSquare footage of porchUnattached structures (sheds, barns, fences, etc.) on property?Unattached Structure ValueDistance to fire hydrantMiles to fire stationSwimming pool?Yes, in groundYes, above groundNoDiving board?YesNo4 ft fence w/ locking gate?YesNoSlide?YesNoBurglar AlarmMonitoredUnmonitoredFire AlarmMonitoredUnmonitoredFire Extinguishers?YesNoDeadbolts on all exterior doors?YesNoGated Subdivision?YesNoTrampoline?YesNoHot tub on premises?YesNoSmokers in household?YesNoPets?YesNoBreed?Bite History?YesNoBy signing below, I certify that the information above is true.
