Current Homeowners Insurance Information
Company Name (not agency):
Policy Expiration Date:	Premium Amount: $
Amount Insured For: (dwelling or coverage A)	$
Policy Type:	-Select- Primary Secondary Rental
Term:	6 Months   1 Year Other:
Personal Liability	-Select-$100K$200K$300K $400K$500K$1 million
Deductible	-Select-$250$500$1000 $2500$5000

Home Information
How Long At Present Address:	Year Home Was Built:
Sq. Footage (excluding garage and basement):	sq. ft. # of Claims In Last 3 Years:

Structure Information
Type	Construction	Roof
-Select- 1 Story 1 1/2 Story 2 Story Split Level Bi-Level Other	-Select- Frame Stucco Masonry Veneer Masonry Fire Resistive Other	-Select- Asphalt Shingle Wood Shingle Tile or Slate Other
Foundation	Garage	Garage Type
-Select- Basement Crawl Space Slab Other	-Select- 1 Car 2 Car 3 Car 4 Car None	-Select- Attached Detached Basement Built-in Car Port None
Last Renovated	Age of Roof	Roof Material
(mm/dd/yy)	yrs.	-Select- Compostion Wood Shingles Clay Tile Metal Other

Features
Bathrooms	Basement	Deck/Porch/Patio	Fireplaces
# of Full: # of Half:	-Select- None Finished Unfinished Sq. Ft.:	Deck Sq. Ft.:  Porch Sq. Ft.:  Patio Sq. Ft.:	# of Chimneys:  # of Hearths:

Additional Features
Heating System	Security Alarm	Fire Alarm	Smoke Detector
-Select- None Electric Gas Oil Propane Solar Other	-Select- None Monitored Not Monitored	-Select- None Monitored Not Monitored	Yes

Additional Comments

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