| Personal
Information |
| Name |
|
| Address |
|
| Suite or Apt. |
|
| City |
|
| State |
|
| Zip Code |
|
| Home phone |
|
| Work phone |
|
| Cell phone or
Pager |
|
| E-Mail Address |
|
|
Information about your home |
| Status |
|
| Number of Units |
|
| Size (square
footage) |
|
| Year Built |
|
| Number of floors |
|
| Garage |
|
| Garage attached? |
Yes
No |
| Number of bathrooms |
|
| Number of fireplaces |
|
| Type of roof |
|
| Age of roof |
|
| Foundation type |
|
|
Other
Information |
| Fire sprinklers |
Yes
No |
| Coverage |
|
| Alarm |
Yes
No |
| Central station
connection |
Yes
No |
| Prior insurance
company |
|
| No.claims in
last 3 years |
|
| Deductible
desired |
|
