YOUR CONTACT INFO:

E-Mail Address:

Name:

Street Address:    Apt. #:

City:    State: MD AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY    Zip Code:

Home Phone:    Work Phone:

ABOUT PROPERTY TO BE INSURED:

Street Address:

City:    State: MD AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY    Zip Code:

Type of Dwelling: Single Family Home Townhome Condo Duplex Other    Approx. Value of Home: Less than $100,000 $100,000-$150,000 $150,000-$200,000 $200,000-$250,000 $250,000-$300,000 $300,000-$350,000 $350,000-$400,000 $400,000-$450,000 $450,000-$500,000 $500,000-$550,000 $550,000-$600,000 $600,000-$650,000 $650,000-$700,000 $700,000-$750,000 $750,000-$800,000 $800,000-$900,000 $900,000-$1,000,000 Greater than $1,000,000

Owner Occupied?: Yes No    If no, is this your Rental Property, Vacation Home, Other ?

Square Footage of Home:    Year Built:    No. of Stories:

Garage?: No Yes- Attached Yes- Detached    If yes, how many cars can it hold?

How many bathrooms?: 1 2 3 4 or more    How many fireplaces (if any) 1 2 3 4 or more

Roof type    Roof age (if known)

Basement? No Yes- Unfinished Yes- Partially Finished Yes- Fully Finished

RATING INFORMATION:

Distant to nearest fire hydrant? Less than 1000 feet More than 1000 feet Don't Know    Distance to closest fire department? Less than 2 miles More than 2 miles Don't Know

Home Security system? No Yes    Fire Supression/Sprinkler system? No Yes    Fire/Smoke/CO Alarms? No Yes

Current/Prior Insurance Company:

Policy Number:    Any Claims in Last 3 Years?: No Yes

ADDITIONAL INFO:

Desired Deductible: $500 $1,000 $2,500

Would you like:
Water/Sewer Backup Coverage?: No Yes    Umbrella Coverage?: No Yes    Floater Coverage?: No Yes

Information on Flood Insurance?: No Yes