• Personal Information
     Name:  Date:
     Home Phone:  Work Phone:
     Address:  City/State/Zip:
     Marital Status:  Spouse Name:
     Insured Occupation:  Spouse Occupation:
     # of Years:  # of Years:
     Work From Home: Yes No  Work From Home: Yes No

    Prior Insurance Information
     Prior Carrier:
     Date Purchased:  Expiration Date:
     Loss:
     Any water damage to any dwelling in last 5 years?: Yes No

    Dwelling Information
     Year Built:  Total Square Feet:
     Year Updated:  Wiring:   Plumbing:   Roof:   Heating:
     Earthquake Retrofitted:  Bolted to Foundation?: Y N  Cripple Walls?: Y N
     Water Heater Strapped to Structure?: Y N
     # of Stories:  Construction:
     Foundation:  Roof Material:
     Garage - # of Cars:  Garage Type:
     # of Bedrooms:  # of Bathrooms:
     Other Rooms:  Den     Family Room     Kitchen Nook
     # of Fireplaces:     Hearths:     Chimneys:
     Type of Heating:  Central     Wall Furnace     Gas     Electric
     Central Air: Y N  Ducts:
     Screened Patios:  Square Feet:
     Breezeways:  Square Feet:
     Porches:  Square Feet:
     Balconey / Deck?: Y N  Square Feet:
     Finished Attic?: Y N  Square Feet:
     Finished Basement?: Y N  Square Feet:
     Walkout Basement?: Y N  Square Feet:
     Woodburning Stove?: Y N  
     Outdoor:  Pool     w/Diving Board     Fenced In     Spa     Jacuzzi
     Class of Construction:  Condition:
     Feet to Nearest
    Fire Hydrant:
     Miles to Nearest
    Fire Dept.:
     Pets?: Y N  Biting History: Y N
     Fire/Security:  Dead Bolt Locks     Fire Extinguisher     Smoke Detectors
     Security Alarm (Monitored)     Security Alarm (Not Monitored)
     Fire Alarm (Monitored)     Fire Alarm (Not Monitored)

    Additional Comments
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