Address:   
Address 2:
City:               State: 
Zipcode:    
County:         
Email:        
Phone #:         Fax # : 

Date Of Birth:

What insurance type do you need?:
Homeowner - I own and need content coverage
Condo - I own but only need content coverage
Townhome - I own but only need content coverage
Landlord - I own but rent to another party
Renter - I rent and only need content coverage

Year Home was built:
Number of Stories:     select 1 1 1/2 2 3 4 or more Bi-level Tri-level
Property Type :          select Standard - most common Luxury Manufactured Home / Mobile Home
Extrerior Walls:         select More than 50% Brick All Brick Stucco Exterior Wood Frame

Garage Type:             select Built In Attached to Home Not Attached to Home Carport No Garage
Garage Capacity:       select 1 1 1/2 2 2 1/2 3 4 4 or more
Basement Type:         select No Basement at all Less than 50% finished More than 50% finished
Home Security System:  select No security alarm system Alarm sounds in home only Signals to a monitoring alarm system
Roof Type:                 select Asphalt composition (most common) Wood shake or trested wood slats Tile or clay shingles (Spanish style) Metal Flat Roof

Square Footage (excluding basement): 
Number of Bedrooms: 
Number of Full Bathrooms:     with shower / bath tub
Number of Half Bathrooms:    without shower / bath tub
Number of Fireplaces: 
Number of Decks:      

Potential Disconts: Deadbolts                 Smoke Alarms
                                 Fire Extinguishers     Nearby Fire Hydrant
                                 Manned Fire Station within 5 miles

House Add-ons:     Central Air Conditioning Sauna
                                Hot Tub      Wood Burning Stove
                                In-Ground Swimming Pool Pool is fenced in
                                Sump Pump

Do you own any Dogs of these breeds?
                                Rottweiler Pittbull
                                German Shepard   Chow
                                Doberman

If not, do you have home insurance coverage? Yes No
Name of Insurance Carrier (if yes):
Date Policy Expires / Expired:    
Estimated Replacement Cost:  $

Future Coverage Needs
Deductible : 100 250 500 (most common) 1000 5000
Liability Protection : 100,000 300,000 500,000
                      1,000,000 (umbrella liability)
                      2,000,000 (umbrella liability)
Additional Coverages Needed:
                     Sewer Backup Protection     Earthquake Protection

Is there a Smoker in your household? Yes No

List any recent Claims: Date
                                        Claim Type select weather theft vandalism fire water other
                                        Claim Amount  $
                                        Description:
                                       

Personal Property Details :
              Antiques          Appraised Value  $
              Collectibles      Appraised Value  $
              Computer Equipment        Value  $
              Fine Arts          Appraised Value  $
              Guns                Appraised Value  $
              Jewelry            Appraised Value  $
              Musical Instruments          Value  $
              Photography    Appraised Value  $
              Silverware       Appraised Value  $
              Tools               Appraised Value  $

How would you rate your Credit :
    Excellent - established credit history - no current or past problems
    Good - occasional missed payment - no collections
    Some Problems - judgement or collections filed
    Major Problems - loan defaults, bankruptcy or
           non-payment of taxes in the last 7 years

Comments: