| Today's date (MM/DD/YYYY) * |
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| First Name * |
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| Last Name * |
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| Property address * |
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| City * |
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| State * |
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| Zip * |
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| Mailing address (if different) |
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| City |
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| State |
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| Zip |
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| Is this your primary residence? * |
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| Year home was built * |
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| Number of stories * |
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| If over 25 years old, what year was plumbing updated? |
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| If over 25 years old, what year was wiring updated? |
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| If over 25 years old, what year was heating updated? |
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| What type of heating * |
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| Is heating controlled by a thermostat? * |
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| If built prior to 1960, is home retrofitted? * |
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| If built prior to 1960, is home bolted to the foundation? * |
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| If built prior to 1960, is water heater braced to a wall? * |
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| If built prior to 1960, is chimney anchored to the building? * |
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| What is the total square footage? * |
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| What is the construction type? * |
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| Is your home a tract or custom home? * |
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| What is the foundation? * |
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| Is there a basement? * |
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| What is the size of the basement? |
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| Is basement finished or unfinished? |
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| Number of car garage? * |
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| Is garage attached or detached? |
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| Is there a carport? * |
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| Number of bedrooms * |
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| Number of full bathrooms * |
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| Number of 3/4 bathrooms * |
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| Number of 1/2 bathrooms * |
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| Number of fireplaces * |
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| Number of chimneys * |
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| Is there central air-conditioning? * |
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| Does the AC use the same ducts as heater? |
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| Size of enclosed patio (if applicable) |
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| Size of open patio (if applicable) |
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| Size of breezeways (if applicable) |
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| Size of finished attice (if applicable) |
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| Type of roofing * |
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| Age of roof * |
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| Condition of roof * |
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| Is there a pool? * |
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| If yes, is the property fenced? |
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| Do you own any dogs? * |
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| If yes, how many and what breeds? |
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| Please list any other residential properties (addresses) owned, leased or rented out |
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| Are there any claims in the last three years against any of you properties? If yes, please describe (include date and amount paid) |
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| What percentage of flooring is wood? * |
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| What percentage of flooring is carpet? * |
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| What percentage of flooring is tile? * |
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| What percentage of flooring is not wood, carpet or tile? * |
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| Verification: |
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