General Information:

Name

Address

City

State

Zip

County

E-mail

Phone

Best Time to Call

Current Homeowners Insurance Company (not your agent’s company):

Company Name

Policy Expiration Date

Amount Insured For ($)

Annual Premium Amount ($)

Term

 6 months

 1 year

 Other

Information about your home:

How long have you lived at your present address?

Number of claims in last 3 years?

Square feet in home (excluding garage and basement)?

What year was your home built?

Structure Information:

Construction

Frame or Stucco Masonry or Veneer Masonry Other

Type

1 Story 1 1/2 Story 2 Story Split Level Bi-Level Other

Roof

Composition Shingle Wood Shingle Tile or Slate Metal Other

Age of Roof

 Yrs

Foundation

Crawl Space Basement Slab Other

Garage Type

Attached Detached Basement Carport None

Garage Size

1 Car 2 Car 3 Car 4 Car Other None

Home Features:

Bathrooms

Full:

Half:

Basement

None Finished Unfinished

Sq. Feet:

Square feet of deck

Square feet of porch

Square feet of screened patio