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Contact Information
Full Name
Phone Number
Address
Fax Number
City
Email Address
State
Zip Code
Contact me by
Phone
Email
Fax
Any method above
Questions
Property Address
City
County
Sub Division
Inside or Outside City Limits
Inside
Outside
Year Built ?
Dates of Wiring ?
Dates of Plumbing ?
Dates of Heating ?
Age of Roof ?
If over 30 years old, any updates to the roof
Yes
No
Roof Condition ?
Excellent
Good
Poor
Type of Roof ?
Full Time Resident ?
Yes
No
Swimming Pool ?
Yes
No
Central Heat or Air ?
Yes
No
Is the House Fenced ?
Yes
No
Wood Burning Stove ?
Yes
No
What is the square footage of the house?
How many stories is the house ?
Where is the closest fire hydrant ?
in feet
Where is the closest fire department ?
in miles
Questions
Dwelling Limit
Contents
Liability Limit
$50,000
$100.000
$300,000
Medical Payments
$500
$1000
Any rental properties ?
Yes
No
Any losses in past 3 Years ?
Yes
No
What is the structure of the house made of?
100% Brick
75% Brick
50% Brick
25% Brick
100% Frame
100% Stucco
Comments or Questions
