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Information About Your Home

Current Homeowners Insurance Company (not agency):

Policy Expiration Date (mm/dd/yy):    Amount Insured for:

Deductible: $250 $500 $1,000 $2,500     Premium:

Do you have replacement cost coverage on contents? Yes No

How long at present address: years   Number of claims in last 3 years:

Square footage of home, excluding garage and basement:

Year home was built:

Nearest Fire Station: Distance in miles
Nearest fire hydrant (distance)

Structure Information

Type: 1 Story 2 Story 3 Story Split Level Other    Construction: Frame or Stucco Log Masonry Metal Other    Roof: Asphalt Shingle Wood Shingle Tile or Slate Metal Rolled Other

living space Size Sq. Ft.: Age of Roof (years):    Foundation: Pilings Continuous Slab Other   

Garage Size Sq. Ft.: Garage Type: Attached Detached Basement Built-In Car Port None   Full bathrooms: Half bathrooms:    

Basement: None Finished Unfinished    Basement Sq. Ft.:

Deck Sq. Ft.:     Porch Sq. Ft.:   Screened Patio Sq. Ft.:

Primary Heating System: Wood Electric Gas Oil Propane Solar Other  Secondary Heating System: Wood Electric Gas Oil Propane Solar Other   

# of Chimneys:     # of Hearths:   

   Security Alarm: No Yes    Fire Alarm: No Yes

Sprinkler system?  yes no
Smoke Detector?   yes  no
Fire Extinguisher?  Yes No
Dead Bolt?             Yes No
Trampoline?           yes no

Pets? yes no  what kind?   How many?
Horses / farm animals yes no  what? How many?
Business on premises?  yes no  What type?

note: Not a firm quote or binder. Final premium subject to verification of information.