Last Name *
First Name *
Street Address *
Social Security Number *
Birth Date *
Email Address *
Property Street Address *
Dwelling Type *
Number of Bedrooms *
Number of Bathrooms *
Number of Fireplaces *
How many porches or decks are there *
What year was it built? *
What date was the property purchased? *
What is the construction type? *
How many stories is it? *
If two stories, what is the ground floor square footage? *
Total square footage? *
What is the Distance to Body of Water *
Garage Description *
What type of roof covering *
Was the roof updated
If yes, what year
Does the home have a pool?
If yes, is it fenced?
If there is a pool, is there a diving board
If there is a pool, is there a slide?
What is the distance of fire hydrant? *
Is there a smoke alarm?
Are there fire extinguishers?
Are there deadbolts?
Is the electrical updated?
Are there circuit breakers?
Does the electrical circuit box have copper wiring?
How old is the heating/air conditioning? *
What is the heating system? *
If Oil, where is the tank located? *
Has the plumbing been updated?
Is the plumbing copper?
Does the building have interior automatic fire sprinklers?
Is there a theft alarm?
Is there the fire district?
Are there dogs on the property?
If yes, how many and what is the breed of each dog?
Are there any other pets or animal on the property?
If yes, who many and what is the description of each?
Current Insurance Company
Were there any losses or claims in the last 5 years
If yes, what is the date, amount paid and description of each loss or claim?
Dwelling Amount-Coverage A
Other Structures-Coverage B A
Personal Property-Coverage C
Loss of Use-Coverage D
Premise Liability-Coverage E
Questions or Comments
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