Policy Holder Policy Holder

Contact Name

Email Address

Phone Number

Date of Birth

Social Security Number

Occupation

Policy Location Policy Location

Address

City

State

Zip Code

County

Current Insurance Information Current Insurance Information

Company Name

Current Annual Premium

Expiration Date

Insurance Information Insurance Information

Deductible Desired

Amount of Liability Desired

Hurricane Coverage Desired Hurricane Coverage Desired Yes No

Earthquake Coverage Desired Earthquake Coverage Desired Yes No

Windstorm Coverage Desired (not applicable in all states) Windstorm Coverage Desired (not applicable in all states) Yes No

Pets? If so, what breed?

Dwelling Information Dwelling Information

Is this home owner occupied or a rental? Is this home owner occupied or a rental? Owner Occupied Rental

Estimated Replacement Cost

Square Footage

Year Constructed

Is your home over 20 years old? If so, what updates have been made?

Age of hot water heater?

Roof Type and Age?

How Many Floors? How Many Floors? 1 story 1.5 story 2 story Bi-Level Tri-Level Other

Type of Construction Type of Construction Wood Stucco Masonry Brick Veneer Aluminum Siding Other

Other Home Features Other Home Features

Check all that apply Check all that apply Dead Bolts Smoke Detectors Fire Extinguisher Central Station Fire Alarm Central Station Burglar Alarm Located within 5 miles of Fire Station Located 1000 feet from Fire Hydrant Swimming Pool Trampoline Home Located within City Limits

Claims Claims

List any claims in the last 3 years. Please include date of the claim, amount paid, claim type and a description.

Personal Property Personal Property

Estimated value of your personal property: jewelry&watches, furs, silver, firearms, stamp and coin collections, fine arts and breakable items..