E-mail Address

Phone

  Select Phone Type Cell Work Home Other

  Select Phone Type Cell Work Home Other

Non-Smoker Household?  .. Yes No

Credit Rating (1 = Best, 6 = Worst)  Select.. 1 = Best 2 3 4 5 6 = Worst

Occupancy 

Select.. Owner Occupied Landlord Policy Seasonal Dwelling Second Residence

Home Style

Select.. 1 Story (Rambler) 1 1/2 Story 2 Story Tri-Level/Multi-Level Bi-Level/Raised Ranch Town Home (Middle Unit) Town Home (End Unit)   Year Built

Select.. Asphalt Shingle Tile Rock/Tar Gravel Metal Slate

Square Footage

  Main Floor

Wall Height (Must add up to 100%)

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%   8 Ft

Garage Type

None Carport Attached Built-In Detached   # of Cars  0 1 2 3 4

Heating Type (Gas, Electric., Etc.) 

Central Air?

.. Yes No Evap Cooler

Number of Fireplaces

Masonry Chimney  0 1 2 3 4 5 6     Metal Chimney  0 1 2 3 4 5 6

Home Security

Dead Bolts, Smoke Detectors & Fire Extinguisher .. Yes No

Alarm System None Monitored Alarm (Central) Local Burglar Alarm Local Fire Alarm Local Burglar & Fire Alarm

Number of Bathrooms

Full or 3/4 Baths 0 1 2 3 4 5 6      Half Baths  0 1 2 3 4 5 6

Exterior Wall Construction (Must add up to 100%)

Select... Aluminum or Vinyl Siding Brick Veneer Stone Veneer Stucco on Frame Stucco on Masonry Paint on Masonry Wood Shakes Wood Siding Solid Stone Clapboard (Wood) Clapboard (Redwood) Cement Shingles Asbestos Shingles Solid Brick 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%

Select... Aluminum or Vinyl Siding Brick Veneer Stone Veneer Stucco on Frame Stucco on Masonry Paint on Masonry Wood Shakes Wood Siding Solid Stone Clapboard (Wood) Clapboard (Redwood) Cement Shingles Asbestos Shingles Solid Brick 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%

Select... Aluminum or Vinyl Siding Brick Veneer Stone Veneer Stucco on Frame Stucco on Masonry Paint on Masonry Wood Shakes Wood Siding Solid Stone Clapboard (Wood) Clapboard (Redwood) Cement Shingles Asbestos Shingles Solid Brick 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%

Select... Aluminum or Vinyl Siding Brick Veneer Stone Veneer Stucco on Frame Stucco on Masonry Paint on Masonry Wood Shakes Wood Siding Solid Stone Clapboard (Wood) Clapboard (Redwood) Cement Shingles Asbestos Shingles Solid Brick 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%

Select... Aluminum or Vinyl Siding Brick Veneer Stone Veneer Stucco on Frame Stucco on Masonry Paint on Masonry Wood Shakes Wood Siding Solid Stone Clapboard (Wood) Clapboard (Redwood) Cement Shingles Asbestos Shingles Solid Brick 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%

Floor Coverings (Must add up to 100%)

Select... Carpet Vinyl Hardwood Ceramic Tile Laminated Parquet Marble Slate Brick Stone Ceramic Tile (Imported) 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%

Select... Carpet Vinyl Hardwood Ceramic Tile Laminated Parquet Marble Slate Brick Stone Ceramic Tile (Imported) 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%

Select... Carpet Vinyl Hardwood Ceramic Tile Laminated Parquet Marble Slate Brick Stone Ceramic Tile (Imported) 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%

Select... Carpet Vinyl Hardwood Ceramic Tile Laminated Parquet Marble Slate Brick Stone Ceramic Tile (Imported) 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%

Select... Carpet Vinyl Hardwood Ceramic Tile Laminated Parquet Marble Slate Brick Stone Ceramic Tile (Imported) 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%

Please add any additional comments you may have.

Please remember that the quotes provided are on the basis of the information provided by you. Complete underwriting and other factors will be required to determine whether you are eligible for coverage.