Name

Address

City

State

Zip

Phone

Present Insurance Co.

# of Claims in Past 3 Years

How Long Have You Owned This Home

Type of Home

House Town Home Condominium Mobile Home Other               *

Year Home Was Built

Square Feet

    *

Number of Bedrooms

One Two Three Four Five Six Seven +                       *

Number of Bathrooms

One Two Three Four +                          *

Construction

Frame Brick/Masonry/Stucco Other   *

Garage

None Attached Detached                     *

Type of Heating

Gas Forced Air Electric Fuel Oil Hot Water/Steam Other          *

Electrical System

Circuit Breakers Knob & Tube Fuses            *

Which Satety/Security Devices Are Installed

Smoke Detectors          *

Fire Extinguisher

Deadbolt Locks

Security System

Mark Any Of the Following That You DO Have

Swimming Pool

Jungle Gym

Fireplace

Wood Burning Stove

Would You Be Interested in Receiving a

Combined Quote for Home/Auto Insurance