Applicant Name
Email address*	(required for contact)
Date of Birth
Address
Phone Number
Prior Losses in Household	provide type and date of loss(es)
Do you smoke?	Yes No
Name and phone numbers of all contacts	1. name       phone   2. name       phone   3. name       phone   4. name       phone   5. name       phone
Occupation

Adults in HH

select one 0 1 2 3 4 5 OTHER THAN MYSELF

Dead bolt lock(s)	Yes No
CO2 hydrant	Yes No
Smoke detector alarm(s)	Yes No
Alarm System	Yes No
Fire Sprinklers	Yes No

Year Built
Number of Units	select one Single Duplex Triplex Fourplex 5+
Square feet above ground	sq feet
Square feet of basement (below ground)	sq feet
Percent of basement that is finished	%
Number of full bathrooms	select one 0 1 2 3 4 5
Number of half bathrooms	select one 0 1 2 3 4 5
Number of custom/luxury bathrooms	select one 0 1 2 3 4 5
Location of laundry room	select one 1st Floor 2nd Floor Basement
Number of kitchens	select one 0 1 2 3 4 5
Number of fireplaces	select one 0 1 2 3 4 5    Number of chimneys   select one 0 1 2 3 4 5
Evaporative Air (swamp cooler)	Yes No
Central Air conditioning	Yes No
Percent of ceilings that are vaulted	%
Walk out basement (basement with outside access)	Yes No
Roof Type	Aluminum Asphalt Shingle Asphalt/Fiberglass Concrete/Cement Copper Plastic Recycled Roof Rock / Tar & Gravel Rolled Asphault (flat) Rolled Asphault (peaked) Sheet Metel Panel Single Ply Membrane Slate Spanish Tile (clay) Steel (tile or shingle) Synthetic Shingle / Tile Wood Shingle / Shake       Other - specify
year roof built
Exterior Construction Type	Adobe Aluminum/Plastic/Vinyl over frame Asbestos siding Composite roll siding Frame with 0-33% masonry veneer Frame with 34-66% masonry veneer Frame with 67-100% masonry veneer Log Home Log Home with finished interior Solid masonry - brick, stone, etc. Wood siding       Other - specify
Exterior Walls Please enter percentage values for all that apply (total should = 100%)	% - Adobe % - Logs % - Clay Tile % - Glass % - Granite / Marble % - Solid Brick % - Brick Veneer % - Solid Stone % - Stone Veneer % - Stucco on Frame % - Paint on Masonry % - Stucco on Masonry % - Siding - Wood % - Siding - Aluminum / Vinyl % - Shake Shingles - Wood % - Shingles - Asbestos % - Shingles - Cement % - Shingles - Clapboard % - Clapboard Wood % - Clapboard Redwood
Interior Wall Construction	select one Drywall / Sheetrock Plaster
Interior Wall Finish Please enter percentage values for all that apply (total should = 100%)	% - Sheet Paneling % - Ceramic Tile % - Imported Ceramic Tile % - Mirrors % - Brick Facing % - Solid Wood Paneling % - Paint % - Marble % - Foil Wallpaper % - Bookcase Walls % - Grass Cloth Paper
Floor Covering Please enter percentage values for all that apply (total should = 100%)	% - Brick % - Carpet % - Carpet (Custom) % - Carpet over hardwood % - Carpet over hardwood (Custom) % - Ceramic Tile % - Ceramic Tile (Imported) % - Hardwood % - Laminated Flooring % - Marble % - Parquet % - Slate % - Stone % - Vinyl
Style Code	select one 1 Story 1½ story 2 Story 2½ story 3 Story Modular Split Level Townhome - middle unit Townhome - end unit Bi-level / Raise ranch (immediate stairs) Geometric Dome Underground
Garage	1 Car - Attached 1 Car - Dettched 1 Car - Built-in 1 Car - Carport 2 Car - Attached 2 Car - Dettched 2 Car - Built-in 2 Car - Carport 3 Car - Attached 3 Car - Dettched 3 Car - Built-in 3 Car - Carport 4 Car - Attached 4 Car - Dettched 4 Car - Built-in 4 Car - Carport
Extras Select all that apply	Metal Spiral Staircase Central Vacuum Intercom System Jacuzzi Tub Hot Tub Wet Bar - how many? Elevator Linen Chute Sauna Dumbwaiter Chairlift Commercial Stove Sub-zero Refrigerator Copper Range Hood Greenhouses Screen Pool Enclosure Solar Panels - how many? Stained Glass Windows - how many? Spiral Staircase Ornamental Stairs Electric Air Cleaner Laundry Tub Indoor BBQ Additional Furnace Trash Compactor Skylights Exterior Shutters Interior Shutters Swimming Pool Built-in Bookcase Deck - sq feet Open Porch - sq feet Enclosed Porch - sq feet Breezeway - sq feet Balcony Elaborate Roof Attached Carport Breezeway Open Breezeway Screened Composite Deck Central Stereo System Patio Cover Porch Open Porch Screened Redwood Deck Solar Room Wood Deck Wood Spiral Staircase Atrium Doors - how many? Atrium Windows - how many? Bay windows - how many? Exterior Shutters- how many? French Doors - how many? Greenhouse Windows- how many? Picture Windows - how many? Sky Lights- how many? Sliding Glass Doors- how many? Walk-in Cooler       Other -

Coverage Information	select one Homeowner Renter Landlord Mobile Home Condo
Liability Limit Wanted	select one $100,000 $300,000 $500,000 $1,000,000
Deductible Wanted	select one $250 $500 $750 $1,000 $1,500 $2,500 $5,000
If Mortgage provide load balance	$
Extras	Provide item and value of item(s). (Jewelry, Furs, Guns, Electronic Equipment, Additional Premises, Jet Skis, etc.)