Name*

Address

 

City

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Zip

Phone

Fax

Email*

How did you hear about us?

Occupancy

• Owner Occupied
• Rented / Non-Owner Occupied
• 2nd Home
• Seasonal
• Vacant

# of Non-Relatives in Home (Roommate, Fiance, Friend, Etc)

Renting a room to anyone?

• Yes
• No

Currently have a policy in place now?

• Yes
• No

Is the home in escrow?

• Yes
• No

Has the home been in foreclosure in the past 3 years?

• Yes
• No

Year built?

Square feet?

# of Stories?

Roof Type

• Composition shingle
• Tile
• Gravel
• Wood
• Other

Garage

• Attached
• Detached
• Built-in (room over garage)
• Carport
• # of cars the garage can hold:

Alarm?

• Central
• Local
• None

Dogs in household?

• Yes
• No
• Quantity
• Breed(s)

Any unique features of the home?

• Yes, list:
• No

Gated community?

• Yes
• No
• Is there a guard shack at entrance with a 24 hr guard?  Yes   No

Trampoline on the premises?

• Yes
• No

Any claims in the last 3 years?

• Yes. Describe briefly:
• No

In home business?

• Yes, please describe
• No
• If any foot traffic (people) to your home for business reasons, please list:
  
• If any business equipment in home, please list:
  

100% Copper pipes

• Yes
• No

Comments