Date: __/__/__. Time:__________________________________
Name: ____________________________________________
SS#:________-________-________
DOB: __/__/__. (H)Home phone #: _________. (W)Work phone #:_________.
PROPERTY ADDRESS:____________________________________________
Owner Occupied: Yes. or No. Tenant Occupied: Yes. or No.
Current value of property (if known). ___________________________________.
Amount of coverage desired: _________________________________.
Contents coverage desired: _________________________________.
Present coverage (if any). ___________________________________.
New purchase: Yes. or No.
Type of construction:(circle one) BRICK/ FRAME/OTHER:
IF OTHER PLEASE SPECIFY_________________.
Square footage: ________sq ft. Year built: ______. Number of stories: _____.
Type of roof:______. Roof age:______. # of Layers:______
# of bedrooms: ________. # of baths: _____. Fireplace: Yes. or No. (#of______)
Separate dining room: Yes/ No. Separate den: Yes/ No. Utility room: Yes/ No.
Foundation (circle one). Concrete slab or Pier and beam.
Swimming pool: Y/N. Trampoline: Y/N Hot Tub: Y/N
Garage area (circle one). One car/ Two car/ Carport/None
If there is a garage: Attached or Detached
Central heating/air: Y/ N. ,..if no. then what type: Heat or A/C__________________
Any dogs?: Yes. or No. ...if yes, then how many and what breed? __________________. Biting history?: Yes. or No.
ANY CLAIMS-within the last 3 years on any property you own: Y/N.
If the house is over 35 years old:
Plumbing update:___________ Electrical:___________
Any other comments on this Risk: ______________________________________________________________________________
______________________________________________________________________________
How did you hear about our agency:
______________________________________________________________________________
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