PERSONAL
INFORMATION
Your name:
First:
Last:
E-mail address:
Phone number:
Daytime:
Current Living Address:
City:
State:
Zip code:
Social security number:
Date of birth:
If
New Home Address
City
State
Zip code:
STRUCTURAL INFORMATION ( )
How many
stories is your home?
Select...
1 Story 1 1/2 Stories 2 Stories 2 1/2 Stories 3 stories 4 or more stories
Bi-level Tri-Level
What is the total square
footage ?
WHAT IS THE STRUCTURE OF THE
FOLLOWING
Exterior of
your home:
Select... Adobe Aluminum Siding
Asphalt Brick Veneer Brick Solid Cement Fiber Clapboard Concrete Block Concrete-Precast
Logs Log Siding Mineral Fiber Painted Masonry
Slump Block
Split Block
Stone-Precast
Stone-Solid Stone-Veneer Stucco-On-Frame Stucco-On-Masonry
Wood Shakes
Wood Siding
Other
Garage:
Select...
None Attached - 1 car
Attached - 2
car Attached
- 3 car Basement - 1 Car
Basement - 2
Car Basement
- 3 Car Built-in - 1 car
Built-in - 2
car Built-in
- 3 car Carport - 1 car
Carport - 2
car Carport -
3 car Carport w/storage -
1 car Carport w/storage -
2 car Detached - 1 car
Detached - 2
car Detached
- 3 car
DO YOU HAVE THE FOLLOWING IN YOUR
HOME
Swimming
pool?
No
City Water
GENERAL QUESTIONS
Year home
built:
Did you
experience any loss or claims in the last 3
years?
No
PROTECTIVE DEVICES
Security or Fire alarm?
Select... Smoke Detectors Central Fire station
Deadbolt locks?
Yes
No
AGE OF THE FOLLOWING
Roof
Select...
1 year old
2 years old
3 years old
4 years old
5 years old
6 years old
7 years old
8 years old
9 years old
10 or greater
Wiring
Select...
1 year old
2 years old
3 years old
4 years old
5 years old
6 years old
7 years old
8 years old
9 years old
10 or greater
Select...
1 year old
2 years old
3 years old
4 years old
5 years old
6 years old
7 years old
8 years old
9 years old
10 or greater
HOMEOWNERS COVERAGES AND
DEDUCTIBLES
Dwelling (Replacement
cost of your home):
(...what is the value of your home
$
type "Renters
Insurance
Personal
liability:
$ Select... 100,000 - included 200,000 300,000 500,000
(...coverage for a lawsuit...)
Medical
payments:
$ Select... 1,000 - included 2,000 3,000 4,000 5,000 7,500 10,000 25,000
(...if someone gets injured on your prop.)
Deductible:
$ Select... 250 500
1,000 2,500 5,000
OPTIONAL QUESTIONS
Do you want earth quake coverage?
Yes
No
Do you
want backup of sewers and drain coverage?
Yes No
