First Name: Last Name:  

Street:

City: State: Zip:

Phone: Fax Number:

Email:

Best Way to Reach you: Phone Fax Email

Property Address

Address: City:

State: Zip:

Current Coverage

If you currently have a policy in force on this property, please fill in the following:

Dwelling: $ Other Structure: $

Personal Property: $ Liability: $

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

New Home Owners

Purchase Price: $

Underwriting Information

Age of Home: years

Number of Families: 1 2 3 4 Number of Stories: 1 2 3 4

Type of Structure: Frame Brick/Stone Log Total Living Area (if known): sq.ft.

Number of Open Porches: Number of Enclosed Porches:

Number of Decks:

If this property is more than 25 years old, have there been significant updates to any of the following systems (check if Yes): Electrical Plumbing Heating Roof

Basement is: Slab Unfinished Finished
If finished, what percent of the total basement is finished? %

Attached Garage: None 1 car 2 car 3 car more Detatched Garage: None 1 car 2 car 3 car more

Carport: None 1 car 2 car 3 car more Basement Garage: None 1 car 2 car 3 car more

Number of Fireplaces:

Do you have?

Number of Dogs: Breeds of Dogs:

Number of Horses:

Describe any detached structures:

Pool: None above ground inground

Premises Alarm: None Local Central Station

Smoke Detectors: Yes No

Do any residents of this property smoke: Yes No

Scheduled Items

Jewelry $ Computers $

Silverware $ Furs $

Fine Arts $ Other $

Description of Other Scheduled Items:

In Home Business: Yes No
If yes, type of Business:

Have you had any Home Owners Losses in the last 3 Years?: Yes No
If Yes, please fill in the following:

1. Year: Amount of Loss: $ Description of Loss:
2. Year: Amount of Loss: $ Description of Loss:
3. Year: Amount of Loss: $ Description of Loss:

Additional Comments: