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Customer Info:
Name:
*
First
Last
Phone:
Area Code
-
Phone Number
E-mail:
*
Address:
*
Street Address
Street Address Line 2
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Dwelling Info:
Year Built:
Total Square Footage:
Substructure:
Select value
Basement
Slab on ground
Crawlspace
Year roof last replaced:
If you selected Basement is it:
Select value
Finished
Unfinished
Amount of coverage:
Deductible:
Select value
500
1000
2500
Liability:
Select value
300,000
500,000
1,000,000
Do you have a woodburning stove?:
Yes
No
Burglar or Fire Alarms?
Yes
No
Burglar or Fire Alarms? If yes select one:
Select value
Local
Central
Additional Info:
Garage:
Yes
No
#Car(s)
Select value
Attached
Detached
Any other structures on property:
Yes
No
Amount of coverage::
Miles to Fire Department:
Fire Hydrants?
Yes
No
Distance from hydrant:
Is house visible by 5 other houses?
Yes
No
Swimming Pool?
Yes
No
Swimming Pool if yes is it:
Select value
In-ground
Above ground
Swimming Pool is it fenced in?
Yes
No
Trampoline
Yes
No
Member of any groups?:
Senior
College Gradate
Credit Union
Professional (teacher, engineers, CPA, doctor)
Other
Additional Comments:
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