Personal Information

Name:
Address 1:
Address 2:
Phone:

Coverage Information

Dwelling Coverage: $	Under 10,000 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90,000 100,000 110,000 120,000 130,000 140,000 150,000 160,000 170,000 180,000 190,000 200,000 Over 200,000
Type of Coverage:	Home Renters Condo Dwelling Fire
Construction Type:
Year Built:
Deductible: $
Endorsements:
Earthquake:
Flood:

Dwelling Information

Stories:	1 2 3 4 5 6
Fireplaces:	0 1 2 3 4
Bathrooms:	0 1/2 3/4 1 1-1/2 1-3/4 2 2-1/2 2-3/4 3 3-1/2 3-3/4 4 4-1/2 4-3/4 5 5-1/2 5-3/4 6 6-1/2 6-3/4
Car Garage:	NONE 1 car 2 car 3 car 4 car 5 car 6 car
Garage Type:	None Attached Detached Built-in
Exit/Entry Door:	1 2 3 4
Square Feet:
Basement Square Feet:
Walk Out?	Yes: No:
Porch/Patio Square Feet:
Deck Square Feet:
Percent Finished:
Roof Type:
Cooling Type:
Built-in Items:
Pets/Breed:
Losses:
Trampoline:	No Yes
Swimming Pool:	No Yes
Hot Tub:	No Yes
Business on Premises:	No Yes
Day Care:	No Yes