Full Name:
Address:
City
State:
Zip Code:
If Outside City Limits,
Miles to Dept:
Feet to Hydrant:
Social Security # of
Square Footage:
1
2
3
4+
# of Stories:
Dwelling
Co/op
Home
Own a Condo
Building Type:
Frame
Brick over Frame
Solid Masonry
Other
Construction Type:
Home Extras
Year Built:
Check If "Yes"
Smoke Detectors:
Central Station Burglar:
Dead Bolts:
Central Station Fire:
Fire Extinguisher:
Have any of the following been updated in the past 20 years?
Roof:
Plumbing:
Heating:
Electrical:
Underground
Above Ground
Basement
If Oil, Where is the
Electrical system
Do you need special
Have you had any losses
Do you own a swimming pool?
If yes, type of pool:
Fenced In?
Do you own or rent any other
Current Insurance Company:
If renting: number of
$250
$500
$1000
Deductible
$1,000
$5,000
$100,000
$300,000
$500,000
$1,000,000
