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Last Name

Mailing Address

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Day Time Phone (no spaces)

Cell/Other Phone

Email

How would you like to be contacted? Select Type Phone Cell/Other Email U.S. Mail

Current policy in force? Yes No

Policy Number

Dwelling Information

1. What year was your home built?

Type of home? Select Type 1-Family 2-Family 3-Family

2. What style is your home?

3. What is the total square footage of the finished living area of your home?

4. Does your home have a:

Deck Sq. Ft.

Cathedral Ceilings % of home

Breezeway Sq. Ft.
Is Breezeway: Select Enclosed Screened Open

Porch Sq. Ft.
Is Porch: Select Enclosed Screened Open

5. Which of the following additional features are in your home?

6. Do you have a Garage?

Yes No

Type: Select Attached Built-in Carport Detached

How many vehicles can be parked in the garage? Select One Two Three Four

7. Does your home have a basement?

Yes No

If yes, percentage finished %

8. If your home does not have a full basement, what percentage is:

9. Which materials listed below best describe the materials found in your home? Please indicate the materials as percentages of total (e.g. 5%, 10%, 15%, etc.)

EXTERIOR WALLS:

INTERIOR WALLS:

WALL FINISHES:

ROOF COVER:

CEILINGS:

FLOOR COVERINGS:

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