Personal Information
Name
Address
City		State			Zip
Home Phone		Work  Phone
E-mail Address				Current Homeowners Insurance Company
Present Coverage Amount				Renewal Date

Occupation
Claims in Last 3 Years	0 1 2 3 4
Square Footage - Living Space		Year Home Built

Type	Construction	Garage		Bathrooms
Choose  one 1 Story 1 1/2 Story 2 Story Split Level Other	Choose  one Masonry Fram or Stucco Masonry Veneer	# of Spaces:	Choose  one 1-Car 2-Car 3-Car 4-Car	# of Full Choose  one 1 2 3 4 5 or more
Foundation
	Roof
		Type:	Choose  one Attached Detached Basement Carport Other	# of Half Choose  one 1 2 3 4 5 or more
	Choose  one Tile/Slate Asphalt Wood Other Age:
Choose  one Crawl Space Basement Slab

Basement	Fireplaces	Other Features	Deck	Porch
Finished  Not Finished Sq. Ft.	# Chimneys Choose  one 1 2 3 4 5 #  Hearths Choose  one 1 2 3 4 5	Central Air Conditioning Wet Bar Central Vacuum Whirlpool Tub Security System
			Square Feet	Square Feet
			Patio	Screened Patio
			Square Feet	Square Feet