Full Name: * Address: * City: * State: * - - Choose One - - Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:   Home Phone:   Work Phone:   Location of Dwelling:   Within City Limts Outside City Limits Distance from fire hydrant?   feet Distance from fire department?   miles Type of Construction:   Brick Attached Garage Detached Garage Frame Attached Carport Detached Carport Year of Construction:   Approx. Square Footage: # of Bedrooms:   # of Bathrooms: Any hardwood floors?   sq ft Any tile floors?   sq ft Any fireplaces?   # of stories: Amount of current coverage (if applicable)   Purchase Price Current homeowners insurance company (if applicable)   Expiration date:   Is (or will) the property be mortgaged?   Yes No Do you have any special belongings that would need additional coverage? (if NO please skip) Furs   Jewelry Guns   Silverware Other (Please list item and value):   Deductible   $1000 $2000 1% of policy limit 2% of policy limit Discounts:   Smoke Alarm Dead Bolts Fire Extinguisher Burglar Alarm Inquire about combo discount Have you had a total fire loss or any other insurance loss in the last 3 years?   Yes No Have you ever had a bankruptcy. foreclosure, or ever been in debtors court?   Yes No