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Name: How many people reside in your home? Birth Date: - - (sample: 01 - 24 - 2005) Address: Are there any pets in your home? No Yes City: IF YES, please indicate type, breed, & quantity: State: -- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip: Phone: - - Fax: - - Email: @ Any losses in last five years? No Yes IF YES, please describe with date of loss: What company are you presently insured with? Style of Your Home Type of Garage 1 Story 1-1/2 Story 2 Story Split Level Bi-Level/RSD Ranch Other Other: None Carport Detached 1 Car Attached 2 Car Attached 3 Car Attached 1 Car Built In 2 Car Built In 3 Car Built In Other Other: Year of Construction Total Square Footage Basement Square Footage Percent of Basement Finished Exterior Walls (enter percentage) Type of Roof Wood Siding Stone Veneer Solid Stone Paint on Masonry Aluminum Asbestos Stucco on Masonry Vinyl Solid Brick Wood Shakes Adobe Brick Veneer Shingle Slate Tile Wood Shake Other Other: Other: Heat & Central AC Interior Walls Heat Only Heat and Central Air Drywall Sheetrock Plaster Bathrooms (enter quantity) Fireplaces Full Baths Half Baths 1 2 3 More Than 3 None Deck Breezeway 1 2 None Open Screened None Porch Open Screened None Extra Amenities Enter Quantity if Applicable Spiral Staircase Central Vaccum Sauna Indoor BBQ Elect. Air Cleaner Other: Skylights Exterior Shutters Interior Shutters Garage Opener Wet Bar Jacuzzi Hot Tub No Yes Smoker No Yes Smoke Alarms No Inground Above Ground Pool No Yes Dead Bolt Locks No Yes Fenced Yard No Yes Security Alarm No Yes Trampoline No Yes Fire Extinguisher Additional Coverage Requested (collectables, guns, jewelry) Please double check all your information before sending the Form.