Homeowners 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.