Name
Address
City
State	ZIP
Phone
E-mail
Date of Birth	(MM/DD/YYYY)
Referred by
Current Insurer
Premium	$
How many claims within three years?
Description of claim(s)
Type of Policy	Homeowner’s	Condo
	Renter	Landlord Protection
Coverage	$  Market Value
	$  Contents
Discounts	Non-smoker	Yes	No
	Auto/home	Yes	No
	Central alarm	Yes	No
Year built
Sq. footage
Style code	Bi-level      2 Story      1.5 Story      1 Story
Roof type	Asphalt shingle    Wood shingle
	Other
Exterior walls	Wood siding
	Aluminum/vinyl siding
	Brick
	Stucco on frame
	Other
Interior walls	Drywall/sheetrock   Plaster
Basement	Yes      No
	If yes, % of ground floor       % finished
Number of full baths	Standard     Custom     Luxury
Number of half baths
Number of fireplaces
Additional features	Open porch Screened porch Deck Central air Central vacuum Wet bar Spiral staircase Ornamental stairs Stained glass Pool Sauna Jacuzzi Solar panels Skylights
Garage	Detached    1-Car attached    2-Car attached
	None    Other
Scheduled property	Over $2,500 (Jewelry, fine art, firearms, etc.)   $
Sewer drain backup coverage      Yes      No
Deductible	$250    $500    $1,000    $2,500