Name

Address

County

E-mail

Home Description

Construction
Brick
Frame

Year Built:  

Please advise the date the following items have been updated if home is over 20 years old:

Is your home within 3 miles from a Fire Station?
Yes No

Is your home within 500 feet of a Fire Hydrant?
Yes No

Do you have smoke detectors?
Yes No

If you have any other types of fire or burglar alarms, including sprinklers, describe here.

Do you have fire extinguishers?
Yes No

Are you a non-smoker?
Yes No

If you own autos, would you be interested in combining the autos with the homeowners policy for additional discounts?
Yes No

Coverage Limits

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

List any special personal property items which you desire to schedule separately, i.e., Jewelry, Furs, Silverware:

General Information

Have you had any home insurance claims in the past 5 years? If so, please explain:

Do you own a dog?
Yes No

If so, what breed?

Do you have a trampoline?
Yes No

Current policy expiration date

Comments