Applicant #1 Name

Birth date of Applicant 1

PleaseChoose Male Female

Applicant #2 Name

Birth date of Applicant 2

please choose Male Female

Current Mailing Address

Current City and County

Current State and Zip

Phone number

E-Mail Address

Address to be Insured

City and County

State and Zip

Do you currently have Property Insurance?

Yes

No

What kind insurance and with who?

Home Insurance Renters Insurance Condo Insurance No Prior Insurance

Is this a Primary or Secondary home?

Primary

Secondary

Type of home and Construction

SingleFamily Town House Two Family Residence Three Family Residence Four Family Residence

Frame Brick Veneer Vinyl or Aluminum Log Hardi Plank

Basement and Percentage Finished?

No Basement Basement 0% finished Basement 25% Finished Basement 50% Finished Basement 75% Finished Basement 100% Finished  

Wood deck?

Yes

No

Garage type and number of cars:

Carport Garage No Garage or Carport

1 car 2 Car 3 Car 4 Car 5 Car NA

Is there heated living space above the Garage?

Example: Bonus room or bedroom

Yes

No

How many stories does the home have?

1 Story-Ranch 1.5 Story Bi-Level 2 Stories 2.5 Story 3 Stories Tri-Level

Approximate Square footage of entire home excluding basement:

Year Built

Fire Places

No Fireplace 1 Fireplace 2 Fireplaces 3 Fireplaces 4 Fireplaces

Discounts

Deadbolt Locks, Smoke Detector, Fire Extinguisher?

Yes

No

Monitored Security/Fire Alarm?

Yes

No

Does your Subdivision have a Mandated Homeowner Association?

Yes

No

As part of the application process, we may collect personal information from persons other than you or other individuals proposed for coverage, including credit reports and loss information reports. This information, as well as other personal or privileged information subsequently collected by us, may in certain circumstances be disclosed to third parties without your authorization. You have a right of access and correction with respect to all personal information we collect. If you would like more detailed information in writing about our information collection practices, please let us know.

NOTE: In regard to the statement above, we are required to post this as a process of obtaining Loss Information History and final quoting criteria.  Submitting this form approves the collection of data.  We have not asked for and do not require a social security number in this process.