Date of Birth

Social Security Number

Is there a Co-applicant? If so, please provide name, date of birth, and occupation

Is this home a new purchase?

If yes, please provide current/prior address

Year built

Square footage (excluding attached garage)

Contruction type

Number of Floors including basement

Burglar Alarm?

Fire Alarm?

If Yes, Is it a Central Station or Local?

Any steps going up to your front door?

If yes, how many?

Is there a railing?

What type of siding does your home have?

Do you have any pets or exotic animals? If so, please list species & breed.

Do you have a swimming pool?

If yes, is the pool above ground or in ground?

Diving Board?

Slide?

Is the backyard fenced with a self-locking gate?

What type of heat does the house have?

If oil heat, where is the oil tank located?

Is any portion of the roof flat?

When was the last time the roof was redone?

When was the last update for the heating system?

When was the last update for the electric?

When was the last time the plumbing was upgraded?

What type of basement do you have?

Do you currently have insurance?

If yes, please provide current carrier's name & expiration date

Deductible Amount

How much coverage is currently on the house?

Do you have a garage?

Do you own a boat?

If yes, please provide length & engine HP

What company is your car insurance with? (Discounts available if we have your auto insurance)

Do you carry flood insurance?

Do you own any other properties or vacant land?

Do you have anything of exceptionally high value in the home? (Jewelry, fine arts, furs, etc.)

Any business conducted from home?

What is your occupation?

Do you have a sump pump in your basement?

Is there a trampoline on the premises?

Do you have a deck?

If yes, how many square feet roughly?

Is there a woodburning stove in the house?

How many bathrooms are in the house?

Mortgage name address & loan number

Loan Amount?

Who pays the premium? You or mortgage?

Do you have Life Insurance?

How did you hear about us?

Year

Make

Model

Vehicle Identification Number (VIN)

Driver's License #

Date of Birth

Social Security Number

Vehicle Use

# of Miles To/From Work & # of Days Per Week (if applies)

Liability Limits Requested

Comprehensive & Collision Deductibles

Lienholders on vehicle?

Prior Insurance Company

Current Policy Expiration Date

Any other occupants in your household? Please list all occupants.

If other occupants, list date of birth and driver's license numbers for each.