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| Name (including spouse): |
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| Location Address: |
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| Phone Number: |
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| Township: |
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| County: |
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| Miles to Fire Department: |
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| Feet to fire hydrant: |
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| Mailing Address (if different): |
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| Type of home: |
House
Trailer
Modular (Please include Lot #)
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| If it's a modular, is it: |
Titled
Deeded
HUD
Boca |
| Is there a mortagee? (give address) |
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| Year the home was built: |
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Have there been updates?
Include Year. |
Wiring
Plumbing
Heat
Roof
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| Number of Stories: |
3
2
1.5
1 |
| Is there a basement or crawl space? |
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| Is the basement finished? |
yes no |
If it's a Trailer,
is it on a permanent foundation? |
yes no |
| Total square feet: |
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| Trailer length x width: |
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| Any additions to trailer? |
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| Trailer make: |
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| Trailer model: |
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| Trailer serial number: |
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| Is the house: |
Stone
Brick
Vinyl
Aluminum
Wood
Stucco |
| Is the Roof: |
Shingled
Tin
Cedar shake
Clay Tile |
| Current Insurance Company: |
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| Liability Limits: |
300
500 |
| Current Deductible: |
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| Medical payments to others? |
0
1000
3000
5000 |
| What is the current dwelling value? |
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Have you had any claims in the past 5 years?
yes
no |
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| How many household members are there? |
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| Owner One's date of birth: |
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| Owner Two's date of birth: |
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| Owner One's occupation: |
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| Owner Two's occupation: |
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| Does anyone in the home smoke? |
yes
no |
| Is there a trampoline? |
yes
no |
| If yes, is it netted? |
yes
no |
| Is there a pool, pond or
hot tub? |
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| If yes, is it fenced? |
yes no |
| What percent of the home is: |
Carpet
Harwood
Tile Linoleum
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| Any of the following windows? |
Bay
Bow
Picture |
| Any of the following doors? |
Sliding
glass
French |
Type of walls and ceilings:
( dry wall, tongue and groove..) |
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| Is there a custom kitchen, basic or semi basic
kitchen? |
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| Number of full bathrooms: |
1 2
3 |
| Number of half bathrooms: |
1 2
3 |
| Is there a garage? |
Attached
Detached
No garage |
| What size is the garage? |
1
car
2
cars
3
cars |
| Are there any other buildings on the premises? |
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| Are there smoke detectors? |
yes
no
How many?
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| Is there a neighborhood watch? |
yes
no |
| Is there a central alarm system? |
yes
no |
| Is there a deck or patio? |
yes
no
How many square feet?
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| Are there skylights? |
yes
no |
| Is there air-condintioning? |
yes
no |
| Is AC on same vents? |
yes no |
| Is there a woodstove / corn burner? |
yes
no |
| Is there a fireplace? |
yes
no
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| If yes: |
Chimney
Gas |
| List any pets or animals: |
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| Type of dogs: |
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Are there any extras:
(spiral staircase, central PA, central vacuum, bar,...) |
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| Are you a member of a
group? |
Credit Union :
Alumni :
Other :
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| Which would you prefer to be
contacted by? |
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| If contact is by phone, the
best time to reach you is: |
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