Please provide the following information for your home quote:

Residence Type:House Condo Apartment Mobile Home Farm Other

Residence is: Owned Rented

If renting or if you own a condo, please provide us with insurance amount for contents:

Underwriting Information

Home Construction: Brick/Stone Frame			Estimated Year Home was Built
Distance From Home to Fire Hydrant (Example 1000ft)
Wood Burner in Home?	Yes No	Is Primary Heat Wood? Yes No

Smoke Detectors

Yes No

Fire Extinguisher in Home? Yes No

Central Alarm System?Yes No Do you have a pool? Yes No

Pool Fenced? YesNo	Is it kept locked? YesNo	Pool above ground? Yes No
Is Home outside of town?Yes No	If yes, How many homes are visible?
	If Yes, how may miles to the fire station?
	If Yes, Is home in housing development?		YesNo
	If in Development area, how many units are there?

Is any business conducted at your home?	Yes No
Any full time residence employees?	Yes No
Any flooding, brush hazard, landslide hazard, etc?	Yes No
Any other residence owned, occupied or rented?	Yes No
Does any applicant own or are there any exotic pets or animals kept?	Yes No
Is your home on more than 5 acres?	Yes No
During the last 10 years has any applicant been convicted of the crime of arson?	Yes No
Do you own, lease, or occasionally use any recreational vehicles? (including boats, 4wheelers, snowmobiles, jet skis, motor homes, motorcycles)	Yes No
Do you have any special property that you want coverage on for breakage or loss? (Examples could include jewelry, fine arts, camera equipment etc)	Yes No
Have you had any claims on your home during the past 5 years?	Yes No

If Home Is Over 30 Years In Age - Complete Next 4 Questions

1.	When was wiring last updated	Year Est.	Total Partial
2.	When was plumbing last updated?	Year Est.	Total Partial
3.	When was furnace replace?	Year Est.	Total Partial
4.	When was roof replaced ?	Year Est.	Total Partial

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