Current insurance company

Renewal date

Has insurance been declined, cancelled, or  nonrenewed in the last 3 years?

Yes No

Have you had any claims or losses in the  last 3 years?

Yes No    If Yes, please describe. Include date and amount paid.

Type of property

Owner occupied Tenant-occupied dwelling Vacant dwelling  

Amount of insurance desired $

Occupant of property

Named insured (me) Someone other than named insured Unoccupied  

Year Built

Size of Home (Square Feet)

Number of Stories

Type of Construction

(choose one) Brick veneer Frame Aluminum siding Vinyl siding Stucco  

Type of Roof

(choose one) Wood shingle Composition Slate  

Type of Foundation

(choose one) Slab Pier and beam  

Type of Garage

  None   Attached    Detached

Fireplace

  Yes   No

HVAC (Check all that apply)

  Central Heating          Central Air

  Space Heating           A/C Window Units

Updated Items (Year Updated)

  Heating                Plumbing

  Electrical              Roofing

Pets

  Yes   No     How many?
What kind?

Swimming Pool

  Yes   No

Deadbolts on All Doors

  Yes   No

Smoke Detectors

  Yes   No

Monitored Alarm System

  Yes   No

Fenced

  Yes   No