Name:*     DOB:*

Social Security Number:*

Street Address:*

Home Location: (if different from Street Address):

Mailing Address (if different from above):

Phone Number:	Home:*		Work:
	Cell:

Email Address:*

HOME INFORMATION

What year was your home built?

What type of Construction is your home?
Choose one Frame Masonry

How Many family units in your Home?
Choose one 1 2 3 4

What is the occupancy of your home?
Choose one Primary Resident Secondary Residence Seasonal Residence Rented to Others Unoccupied or Vacant

What Type of home do you have?
Choose one Single Story Ranch Cape Colonial Bi-level Tri-level Other

How Many Rooms in your home – Excluding Bathrooms?

How Many Bathrooms?

Type of heat: Choose one Electric Gas Oil Solar   By: Choose one Hot Water Hot Air

Type of Air conditioning:
Choose one None Using heating ducts Separate duct system

Type of Cellar:
Choose one None Crawl Space Full unfinished Full Finished

Do you have a fireplace?
Yes No
           
Do you have a wood, corn or pellet stove?
Yes No

Do you have a Garage?
Yes No

	If yes please describe what type:	Choose one Attached Detached Car port
	How Many Bays:	Choose one 1 2 3 4

Do you have a burglar Alarm?
Yes No

            If yes is it central station reporting?
            Yes No

Do you have Smoke Detectors?
Yes No

Do you have CO2 Detectors?
Yes No

Do you have a fire alarm system?
Yes No

            If yes is it central station reporting?
            Yes No

Do you have a sprinkler system?
Yes No

HOME COVERAGE INFORMATION

Coverage A. Dwelling Limit:*
see Coverage

Coverage B. Other Structures Limit (policy automatically comes with  10% of Coverage A. Limit)
see Coverage

If you need more than the automatic limit please list:

Coverage C. Contents Limit (Policy automatically comes with 50% of Coverage A Limit)
see Coverage

If you need more than the automatic limit please list:

Coverage D. Loss of Use: (Policy automatically Comes with 20% of Coverage A Limit)
see Coverage

If you need more than the automatic limit please list:

Coverage E. Personal Liability: Choose one $100,000 $200,000 $300,000 $400,000 $500,000 $1,000,000
see Coverage

Coverage F. Medical Payments: Choose one $1,000 $2,000 $3,000 $4,000 $5,000
see Coverage

Would you like a quote for Flood Insurance? Yes No

Would you like a quote for Earthquake Insurance? Yes No

Do you have jewelry valued at more than $1000? Yes No

            If yes please list:

Do you have a collection such as antiques, silver, guns, humels or other? Yes No
           
            If yes please list:

Do you operate a business out of your home? Yes No

            If yes please explain:

Is your net worth more than $1,000,000? Yes No

OTHER INFORMATION

Is this a new purchase? Yes No

Have you ever had Homeowners insurance before? Yes No

Have you ever been canceled for Non-payment or any other reason by an insurance Company? Yes No

Have you had any losses? Yes No

            If yes please explain:

Do you have any pets? Yes No

            If yes please describe:

Do you have a trampoline? Yes No

What is the distance to the ocean:

Please use the space below to add any additional comments or concerns