Name:

Address:

City: State: Zip:

Phone #:

E-Mail:

Date of Birth:

Deductible: Select One $100.00 $250.00 $500.00 $1000.00

Liability Limits: Select One $10,000.00 $25,000.00 $50,000.00 100,000.00 $250,000.00 $500,000.00 or more

Dwelling Amount:

Contents Amount:

Do you have pets? Select One Yes No What kind?:

What is the primary material in the construction of your home?:

     Select One Frame, not otherwise described below Select One Modular or Pre-Fab Frame (Wood, Metal, Plastic or Aluminum Brick (Solid Brick, Stone, Masonry) Brick Veneer (Face Brick, Stone, Masonry) Fire Resistive Log

What year was the house built:

Type of Roof: Select One Peaked Flat   Age of Roof:

Type of Heat: Select One Gas Electric Oil Other Is there an Oil Tank? Yes No

Bedrooms: Make A Selection One Two Three Four Five or more Baths: 1 1.5 2 2.5 3 or more

# of Fireplaces: Select One None One Two More Than Two   Swimming Pool: Select One Yes No

Burglar Alarm: Select One Yes No

Basement: Select One Yes No Finished Basement: Select One Yes No

List any claims in the past 5 years: