Name:

Location Address Information:
Street:
City:	State: Zip:

Year Built:
Number of Stories:
Number of Families:
Style of Home:	Ranch Cape Cod Colonial Bungalow Victorian Town House Bi-Level Split Level Raised Ranch Contemporary
Total Square Footage of Living Area:

Basement:	Yes No
% Basement Finished:

Exterior Wall Type:
Roof Material:

Garage?	Yes No
Garage Type:	Attached Detached
Garage Number of Cars:

Attached Structures Please include Sq Footage, this includes porches :
Detached Structures Please include Sq Footage:

Number of SM(4x4) Skylights:
Number of LG(6x6) Skylights:
Number of Picture Windows:
Number of Bay Windows:
Number of Bow Windows:
Number of Sliding Glass Doors::
Number of Atrium Doors:
Number of Atrium Windows:

Please check all that apply:
Single Fireplace:	Wet Bar:
Double Fireplace:	Hot Tub:
Wood Stove:	Jacuzzi:
Kitchen Counter Tops:	Formica Granite
Number of Bathrooms:
Type of Heat:	Electric Oil Gas
Central AC:	Yes No
Fire Alarms:	Yes No
Burglar Alarm System:	Yes No

Date of Home Purchase:

Current Insurance Company:
Insurance Ever Canceled:	Yes No
Insurance Cancellation Reason:
Have you had any property losses in the last 5 years?:	Yes No

Do you own any pets?	Yes No
Explain Pets:

Do you own any recreational vehicles (dune buggy, ATV, etc)?	Yes No
Explain recreational vehicles:

Do you own your residence?	Yes No
Is the house under any renovation or reconstruction?	Yes No
Is house for sale?	Yes No

Do you own a trampoline?

Yes No

Do you have a swimming pool?	Yes No
Type Of Swimming Pool:

Auto Insurance Company:

Best Time To Contact you:	Morning Afternoon Evenings
Preferred Contact Method:	Email Phone Fax
Email:
Phone:
Fax: