Personal Information
Name:
Address:
City:
State:
Zip:
Day Phone:
Night Phone:
Best Time To Call:	AM PM
E-mail Address:
Occupation:
How Long At Present Job:

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

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

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

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

Current Homeowners Insurance Information
Company Name:
Policy Expiration:
Premium Amount:	$
Amount Insured For:	$
Policy Type:	Primary Secondary
Term:	6 Mths. 1 Yr. Other:

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