Personal Information Name: Address: City:   State:   Zip: Day Phone:   Night Phone: Best Time To Call:   AM   PM Email Address: Occupation:   How Long At Current Job:

Current Homeowners Insurance Information Company Name (not agency): Policy Expiration Date:   Premium Amount: $ Amount Insured For: $     Policy Type: Primary Secondary Term: 6 Months   1 Year   Other:

Home Information How Long At Present Address:     Year Home Was Built: Sq. Footage (excluding garage and basement): sq. ft.         # of Claims In Last 3 Years:

Structure Information Type Construction Roof Foundation Garage 1 Story 1 1/2 Story 2 Story Split Level Bi-Level Other Frame Stucco Veneer Masonry Other Asphalt Shingle Wood Shingle Tile or Slate Other Basement Crawl Space Slab Other 1 Car 2 Car 3 Car 4 Car None Age of roof: yrs. Attached Detached Basement Built-in Car Port None

Features Bathrooms Basement Deck/Porch/Patio Fireplaces # of Full:   # of Half:   None Finished Unfinished   Sq. Ft.:   Deck Sq. Ft.:   Porch Sq. Ft.:   Screened Patio Sq. Ft.:   # of Chimneys:   # of Hearths:

Additional Features Heating System Central Air Central Vac Security Alarm Fire Alarm Smoke Detector None Electric Gas Oil Propane Solar Other Yes Yes None Monitored Not Monitored None Monitored Not Monitored Yes

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