Name
Address
County
Phone Number
   
Date of Birth / /   (ex: 02/22/1982)
What year was the home built?
How old is the roof?
How old is the heating system?
How old is the plumbing?
How old is the electrical system?
How many acres do you have?
What kind of wiring does the home have?  
What brand of breaker box?
   
Do you have any recreational vehicles or watercraft? Yes No
If so, what are they and how many do you own?
Are they insured on your homeowner’s policy? Yes No

Do you have any dogs?

 Yes No
If so, what breed(s)?
Do you have any horses? Yes No
If so, how many?
Do you have a pool? Yes No
Do you have a trampoline? Yes No
Do you have a satellite dish? Yes No
Do you have a wood burner? Yes No     If outdoors, how many feet from the building? ft.
Do you have a fireplace? Yes No
Do you have an attached garage? Yes No
How many cars does your garage hold? 1 2 3 4 5 6
Do you have a detached garage? Yes No
How many cars does your garage hold? 1 2 3 4 5 6
Do you have any additional buildings on your property? Yes No
If so, please list what they are and the amount of coverage desired for them.
Do you run any type of business out of your home? Yes No
If so, what type of business?
Do you run any type of business from your property? Yes No
If so, what type of business?
Do you have slate siding or roofing? Yes No
Do you have a tile roof? Yes No
Does the home have smoke detectors? Yes No
   
How far are you from the nearest fire department?
How far are you from the nearest fire hydrant (if applicable)?
Do you live in town or in the country?
   
Who is your current homeowners insurance company?

Have you had any claims on the home?

 Yes No
If so, what was the amount paid on the claim?

Have you ever been canceled or non-renewed from a company?

 Yes No
   
What amount do you want the home insured for?
What amount do you want for liability insurance?
What amount do you want for medical payments coverage?
What amount do you want your deductible to be?

Smoker?

 Yes No
   
Do you have life insurance? Yes No
What is the limit of coverage on your life insurance policy?