Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
*
(###)
###
####
Personal Property Limit
Liability Coverage Limit
Select
100,000
300,000
500,000
Medical Payments to Others
Select
1,000
3,000
5,000
Deductible
Select
500
1,000
2,500
5,000
Off Premises Theft Coverage
Yes
No
Replacement Cost Contents
Yes
No
Replacement Cost Dwelling
Yes
No
Building Additions and Alterations Coverage
Property Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Construction Type
Select
Frame
Masonry
Masonry Veneer
Vinyl Siding
Aluminum Siding
Asbestos Siding
Fire Resistant
Square Footage
Number of Rooms
Number of Apartments
Market Value
Replacement Cost
Structure Type
Select
Dwelling
Apartment
Condo
Townhouse
Rowhouse
Number of Families
Number of Household Residents
Live-Ins
ex. housekeeper, babysitter
Yes
No
Is any resident a smoker?
Yes
No
Purchase Price
Fire Alarm
Yes
No
Burglar Alarm
Yes
No
Fuel
Gas
Oil
Electric
Wood
Coal
Solar
Electrical
Plumbing
Heating
Roof
Exterior Painted
Occupied By
Owner
Tenant
Please check those which apply
Deadbolt
Smoke Detector
Fire Extinguisher
Property Visible to Neighbors
Sprinklers
Gated Community
24 Hour Doorman
Security Cameras
Swimming Pool
Yes
No
If "Yes" to Swimming Pool
Approved Fence
Diving Board
Above Ground
In-Ground
Check those that Apply
At Home Business
Hazard present for flooding, brush fire, forest fire, landslide
Animals/Pets
Property located within 2 miles of tidal water
Property located on more than 5 acres
Please Describe those Checked Above
Trampoline on Premises
Yes
No
Kitchen
0
1
2
3
4
5
6
7
8
9
10
Dining Room
0
1
2
3
4
5
6
7
8
9
10
Living Room
0
1
2
3
4
5
6
7
8
9
10
Den/Study/Office
0
1
2
3
4
5
6
7
8
9
10
Family/Recreation Room
0
1
2
3
4
5
6
7
8
9
10
Bedroom(s)
0
1
2
3
4
5
6
7
8
9
10
Bathroom(s)
0
1
2
3
4
5
6
7
8
9
10
Large Utility/Laundry/Sewing Rooms (Over 150 sq. ft.)
0
1
2
3
4
5
6
7
8
9
10
Finished Basement (Omit if counted as family/rec room)
0
1
2
3
4
5
6
7
8
9
10
Attached 2-Car Garage
0
1
2
3
4
5
6
7
8
9
10
Large Finished Attic (Over 150 sq. ft.)
0
1
2
3
4
5
6
7
8
9
10
Partially Finished Attic
0
1
2
3
4
5
6
7
8
9
10
Partially Finished Basement
0
1
2
3
4
5
6
7
8
9
10
Brick/Stone Exterior Walls
0
1
2
3
4
5
6
7
8
9
10
Central A/C
0
1
2
3
4
5
6
7
8
9
10
Aluminum/Vinyl Siding
0
1
2
3
4
5
6
7
8
9
10
Large Wall Fireplace
0
1
2
3
4
5
6
7
8
9
10
Enclosed Porch/Breezeway
0
1
2
3
4
5
6
7
8
9
10
Clay Tile or Slate Roof
0
1
2
3
4
5
6
7
8
9
10
Any Other Unit Not Listed Here
0
1
2
3
4
5
6
7
8
9
10
Half Bath
0
1
2
3
4
5
6
7
8
9
10
Large Open Porch/Breezeway
0
1
2
3
4
5
6
7
8
9
10
Standard Fireplace
0
1
2
3
4
5
6
7
8
9
10
Unfinished Basement
0
1
2
3
4
5
6
7
8
9
10
Attached 1-Car Garage
0
1
2
3
4
5
6
7
8
9
10
Built-in 2-Car Garage/Carport
0
1
2
3
4
5
6
7
8
9
10
Small Utility/Laundry Sewing Rooms (Under 150 sq. ft.)
0
1
2
3
4
5
6
7
8
9
10
Foyer/Entrance Hall
0
1
2
3
4
5
6
7
8
9
10
Dressing Room/Walk-in Closet
0
1
2
3
4
5
6
7
8
9
10
Unfinished Attic
0
1
2
3
4
5
6
7
8
9
10
Small Finished Attic (Less than 150 sq. ft.)
0
1
2
3
4
5
6
7
8
9
10
Mudroom (With separate entrance)
0
1
2
3
4
5
6
7
8
9
10
Brick/Stone Veneer (Front Wall)
0
1
2
3
4
5
6
7
8
9
10
Dinette or Partitioned Breakfast Nook
0
1
2
3
4
5
6
7
8
9
10
Any Other Unit Not Listed Here
0
1
2
3
4
5
6
7
8
9
10
General Questions/Comments