Homeowners


Residents of Household (answer the following for all residents

Home Information

Flooring

Inside Features

Outside Features

Household Activities

    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?:
    Water heater strapped to the wall?:
    Any security systems:
    Outside Features
    Pool: Hot Tub:
    Jacuzzi: Gated / Fenced:
    Locked: Diving board / slide:
    Trampoline:
    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
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