General Information:

Name:.... ........
Address:. ........
City: ..............
State: ............
Zip:................
Home Phone:....
Work Phone:......
E-mail Address:.

Home Information:
Home Value:.............. $	Fire Place: Yes No
Age of Home:...............	Number of Fireplaces:
Number of Families:.......	Number of Chimneys:
Number of Stories:........	Type of Fireplace: Masonry Metal....
Square Footage:...........	Wood Burner: Yes No
Number of Extra Baths:..	Central Air: Yes No
Construction of Home: Frame   Brick	Finished Attic: Yes No
Is your Home more than 25 years old? Yes No	Do you have Dogs? Yes No
If so, have you updated...	If so, what breed?
Roof? Yes No
Heating? Yes No
Cooling? Yes No
Wiring? Yes No
Basement Information:
Basement:............ Yes No	Walkout Basement: Yes No
Finished Basement: Yes No	Square Footage of Finished Area:
Garage Information:
Garage: .............. Yes No	Number of Cars:
Attached:............ Yes No	Built-in: Yes No
Basement: .......... Yes No	Detached: Yes No
Car Port: ............ Yes No	Construction: Frame   Masonry
Other Structure Information:
Breezeway:.......... Yes No	Three Wall Addition: Yes No
Square Footage:....	Square Footage:
Attached: ........... Yes No	Number of Stories:
Balcony or Deck: .. Yes No	With Foundation: Yes No
Square Footage:....	Three Digit Zip Code:
Losses Last 3 Years:
Type of Coverage Desired:
Deductible.......... $
Liability.............. $
Replacement Cost $
Current Coverage:
Insurance Company	Insured Value $
House .....................$	Other Structures $
Base Premium ...........$	Contents $
Increased Liability .....$	Replacement Cost..................... Personal Property $
Loss of Use ..............$	Liability $
Medical Expense ........$	Credits $
Schedule Property .....$	Recreational Vehicle $
Boats ......................$	Miscellaneous $
Deductible ................$	Total Premium $

Comments: