Date:
Referred by:
Name:
Address:
City: State: Zip:
Phone: Home Work
E-mail address:
Property location:
Distance from a fire hydrant
Distance from a fire station:
Current carrier: Expiration date:
Any prior losses? Yes No
If yes, please comment:
Is this dwelling in a park or private land? Pitched roof Yes No
Any prior losses?
Manufacturer: Model:
Dimension: Year built:
Year updated: Roof: Electric: AMP: Plumbing: Burner:
Basement: Yes No Finished: Yes No Skirted: Yes No
Tie downs: Yes No On slab: Yes No On blocks: Yes No
Garage:Yes No Attached: Yes No Dimensions: Stories:
Number of baths: Full Half
Decks, porches or additions:Yes No Dimensions:
Woodstoves:Yes No Installed by manufacturer: Yes No
Fireplace:Yes No Hearth:Yes No
Swimming pool:Yes No In ground above ground Fenced:Yes No
Any smokers in the household?Yes No Smoke detectors:Yes No Deadbolts:Yes No
Any business conducted at the home?Yes No
Type:
Do you own a watercraft?Yes No
Extension of liability to other property:Yes No Camp Second residents Rental property
Do you own any dogs? Yes No Age: Breed:
Scheduled property:
Jewelry Value: Furs Value: Silver Value: Other Value:
Desired or current coverage limits
Dwelling: Other structures: Personal property: Loss of use:
Replacement cost contents:Yes No Replacement cost dwelling: Yes No
Liability Limit: Deductible:
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