Customer Information
Applicant Name:* (Person 1)	Applicant Name: (Person 2 if applicable)
Home Phone:*	Cell Phone:
Applicant's DOB:*	SSN:
Occupation:	Business Phone:
Spouse's DOB:	Spouse's SSN:
Spouse's Occupation:	Spouse's Business Phone:
Email Address:*

Property Information
Property Address:*	City:*	Zip:*
Are you inside or outside the city Limits?  Inside City Limits  Outside City Limits		If outside, how many miles?:
Distance to Fire Hydrant:	Distance to Fire Station:	Coverage Amount Requested:*
Occupancy / Property Use:  Primary  Secondary  Tenant  Other		Alarm Type:  Fire (Central)  Fire (Local)  Burglar (Central)  Burglar (Local)  Both
Year Home Was Built:	Square Feet:	# of Stories:
Construction Type:  Brick Veneer  Stucco (Frame)  Stucco (Block)  Wood Frame  Block / Mason  Other	Roof Type:  Composition Shingle  Tile (Clay)  Tile (Concrete)  Wood Shake  Metal  Other	Age of Roof:
Foundation:  Concrete Slab  Crawl Space	Window Units:  No  Yes If yes, How Many?	Primary Heating System:
Garage Type:  Attached  Built In  Detached  Carport  None	Number of Cars:
Number of Bathrooms:
Full: Bathroom Type:  Basic  Builders Grade  Custom	Half: Bathroom Type:  Basic  Builders Grade  Custom	Kitchen (Choose One):  Basic  Builders Grade  Custom
Floor Type %: (Ex. Vinyl, Hardwwd, Carpet)		Wall Covering %:

Updates

Electric was updated in: (Year)
 Completed
 Partial
 Not Updated

Heating A/C was updated in: (Year)
 Completed
 Partial
 Not Updated

Plumbing was updated in: (Year)
 Basic
 Partial
 Not Updated

Water Heater Last Replaced: (Year)

Any Attached Structures / Square Ft. (Ex. Porches, Wood Decks, etc.):


Customized Interior Structures (Ex. French Doors, Jacuzzi, etc.):

Fireplace:  Yes  No
Pool:  Yes  No	Fenced:  Yes  No	Diving Board:  Yes  No
Trampoline:  Yes  No	If yes, does it have safety netting?:  Yes  No
Do you own a dog or any other exotic animal?:  Yes  No		If so, Breed or type:
Flood Zone:  Yes  No	Wind Certified (WPI-8):  Yes  No
Purchase Date:	Purchase Amount:	Previous Insurance Carrier:
Previous Coverage Amount:	Expiration Date:
Please explain any previous claims / losses:

Finance Information
Mortgagee Clause:
Bill Mortgage (Escrow)/Insured:	Loan #:	Contact Name / Agent:
Sales / Loan Amount:	Closing Date:
Notes:

* Required Field