Home Application
Contact information:
First Name / M.I.:
Last Name:
Mailing Address:
City:
State:
ZIP Code:
Daytime Phone #:
Evening Phone #:
E-mail:
Current policy expiration date:
MM
/ DD
/ YYYY
Location information:
Is the dwelling located within:
1000 feet of a fire hydrant? Yes No
5 road miles of a responding fire station? Yes No
Is the home in a development? Yes No
Check here if this dwelling is a Condominium
Occupancy and Structural information:
Occupancy:
Number of families
Who lives in the dwelling?
What part of the year is the dwelling occupied?
Is business conducted on the premises? Yes No
Environmental:
Is your area prone to landslides and/or sinkholes? Yes No
Do you have a dog? Yes No, If Yes, What Breed?
Do you have any livestock or exotic pets? Yes No
Do you have a swimming pool on the premises? Yes No
Do you have a wood, oil or kerosene stove? Yes No
Structural:
Year built     (Please enter a four-digit date)
YYYY
Style of dwelling
Number of stories
Is your home accessible to emergency equipment? Yes No
Total living area (approximate square feet)
Exclude porches, basements, decks, breezeways, and garages (but include built-in or basement garages).
Primary exterior wall type
Roof covering
Is there a garage in your home (what # of cars)? Yes No
How many full bathrooms are in your house?
How many half bathrooms are in your house?
Supplemental information:
How many losses or claims have you experienced in the last 5 years?
Replacement Cost:
Please enter your home's replacement cost. This is the cost of rebuilding your home at today's prices, not the sale price.
Enter the replacement cost for your home in the field to the right.
Tip: You may want to use the amount listed under "Coverage A" on your current homeowners policy. 		$
Description of Loses
If your house is more than 30 years old, how long has it been since the roof was replaced years
Discount information:
Protective devices:
Fire extinguishers Yes No
Smoke detectors Yes No
Fire alarm type
Deadbolt locks Yes No
Burglar alarm type
Deductible and Coverage Amounts:
Policy deductible
Coverage A: Dwelling structure replacement $
Coverage B: Other structure replacement
Typical coverage limit: 10% of Coverage A ($10,000)
If left blank,will be based on %'s you listed 		$
Coverage C: Contents or personal property
Typical coverage limit: 50% of Coverage A ($50,000)
If left blank,will be based on %'s you listed 		$
Coverage D: Additional living expenses
Typical coverage limit: 20% of Coverage A ($20,000)
If left blank,will be based on %'s you listed 		$
Extra Coverages on Current Policy $
Personal liability
Medical payments
Extended dwelling replacement cost coverage Yes No
Extended contents replacement coverage Yes No