Name    Address

City    State     Zip

Daytime phone     Best time to call    AM    PM 

eMail

Occupation     For how long?

Company name     Policy expiration date

Premium amount $     Amount insured for $     Policy type Primary Secondary Other

Term 6 Months 1 Year

How long at present address?     Year home was built

Square footage (not counting garage)    Number of claims in the past 3 years

Home manufacturer    Park name

Roof Choose one Asphalt Shingle Fiberglass Shingle Tile Aluminum Tar & Gravel Other    Garage Choose one 1 Car 2 Car 3 Car 4+ Car     Style Attached Choose one Detatched Carport Barn

Foundation Choose one Basement Cellar Slab None Other

Bedrooms 1 2 3 4 5 6     Bathrooms 1 1.5 2 2.5 3 3.5 4 4.5 5     Other rooms None Deck Porch Patio Lanai Other     Square footage

Fireplace     Chimneys --- 1 2 3     Hearths --- 1 2 3     Pool None Above ground Inground

Safety fence     Trampoline     Central heat/air     Heat pump

Window air     Fire alarm     Smoke detector     Security system

Jacuzzi     Hot tub

Weather tight room --- Yes No     Screen room --- Yes No     Utility shed --- Yes No

Carport --- Yes No

Any other attached structures --- Yes No

Please list

Weather tight room --- Yes No     Screen room --- Yes No     Utility shed --- Yes No

Carport --- Yes No

Any other unattached structures --- Yes No

Please list

Fungus/rot/bacteria coverage --- Yes No

Personal effects coverage requested --- Yes No

Special notes on property

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