Name

Email

Phone

Address

City/State/Zip

Date of Birth

Claims in last three (3) years None
1
2
3 or more

Type of policy Homeowner
Renter
Condo Owner
Landlord

Year Built

Square Feet

Home Style 1 Story
2 Story
Tri or Split Level

Garage or Carport None
1-car garage
2-car garage
3-car garage
Detached garage

Number of bathrooms 1
2
3
4
5 or more

Type of Roof Flat
Asphalt Shingle
Tile
Wood Shingles

Exterior Wall Frame
Stucco
Brick
Wood Siding
Aluminum Siding

Fireplace Yes
No

Deck Yes
No

Patio Yes
No

Deadbolts on all doors Yes
No

Smoke Alarms Yes
No

Fire Extinguisher Yes
No

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