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Name: Phone # Work#
Address: City, State & Zip
Current Ins. Co. Exp. Date
Own current home? How long? Current Insured Value
Lienholder Address
Year built SQ. Ft. of main floor Const. Type
IF MOBILE HOME:
Make Model Dimensions
Foundation ? Slab? Crawl Space? Basement? Skirting?
How many stories? Primary type of heat
Do you have a woodstove? Insert? Fireplace? Chimney?
Smoke detectors? Decking? SQ Ft. of Decking
Garage? Attached or unattached? Built in?
Carport? Porches? Open or Enclosed?
Number of baths? Total number of rooms?
Out buildings? Size and function
Laundry room? Family room? Den? Master bath? Sunroom?
Do you have an built in appliances?
Skylights? Ceiling Fan?
Wood Floors? Anything Special or unusual?
Do you have any claims in the last 3 years?
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