Homeowners Name of Applicant Address City State Zip Code Phone Email Residents of Household (answer the following for all residents Resident 1 Resident 2 Resident 3 Resident 4 Home Information Home Occupied Owner Tenant Vacant Year Built Stories Square Footage Built On Slab Raised Foundation Slope Hillside Stilts Type of Roof Number of Fireplaces Age of Roof Number of Car Garage Type Attached Detached Built In Flooring Wood % Tile % Carpet % Vinyl % Inside Features No. of Full Baths No. of 3/4 Baths No. of 1/2 Baths Any Security System Gated Community Has 24 hour guard at gate? Yes No Water heater strapped to the wall? Yes No Any Security System Outside Features Pool Yes No Hot Tub Yes No Jacuzzi Yes No Gated/Fenced Yes No Locked Yes No Diving Board / Slide Yes No Trampoline Yes No Animals Household Activities Any Roommates / Boarders Employees that live / work regularly in the home Is there a business office in your home (be specific) Any claims in the last 5 years? Are you interested in Earthquake, Flood or scheduled jewelry insurance? Comments Send Name of applicant: Address: City: State: Zip Code: Phone: Your Email: Residents of Household (answer the following for all residents) Name: Name: Name: Name: HOME INFORMATION Home occupied: OwnerTenantVacant Year Built: Stories: Square footage: Built on: SlabRaised FoundationSlopeHillsideStilts Type of Roof: # of Fireplaces: Age of Roof: # of car garage: AttachedDetachedBuilt in Flooring Wood % Tile % Carpet % Vinyl: % Inside Features #of full baths: #of 3/4 baths: #of 1/2 baths: Any security system: Gated Community: Has 24 hour guard at gate?: YesNo Water heater strapped to the wall?: YesNo Any security systems: Outside Features Pool: YesNo Hot Tub: YesNo Jacuzzi: YesNo Gated / Fenced: YesNo Locked: YesNo Diving board / slide: YesNo Trampoline: YesNo Animals Household Activities Any roommates / boarders: Employees that live / work regularly in the home: Is there a business office in your home (be specific): Any claims in the last 5 years?: Are you interested in Earthquake, Flood or scheduled jewelry insurance?: Comments We want to make sure that a real person is filling the form.
