Customer information

Name:		Address:
Day phone:	Evening phone:	Best time to reach?:

 Property information

Address:		Home? Condo? Rental property?
Insurance type:		Year built :
Number of stories:  1 2 3 4+	Square feet:	Exterior walls:
Full bathrooms:  1 2 3 4+	Half bathrooms:  1 2	Garage size:  1 2 3 4+
Smoke alarms?:  yes no	Fire extinguishers?:  yes no	# of fireplaces:  1 2 3+
Basement:  unfinished finished	Roof:  asphalt slate other	Deck (sq.ft.):
Central Air?:  yes no	Security system?:  yes no

 Homeowner's insurance claims in last 5 years

Date:	Type of claim:	Amount paid
Detail:

 Coverage

Current insurance carrier:		Liability limit:  100,000 200,000 300,000 400,000 500,000 600,000+
Dwelling value:	Deductible:  250 500 1,000
Additional coverage requested?: