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Applicant Information

Applicant 1

Applicant Name :		Date of birth:	(MM/DD/YYYY)
Gender:	Male Female	Marital Status:
Address:	City:	State:	ZIP Code:
Contact number:		Email Address:
Highest Level of Education Completed:
Current Occupation:

Applicant 2

Applicant Name :		Date of birth:	(MM/DD/YYYY)
Gender:	Male Female	Marital Status:
Address:	City:	State:	ZIP Code:
Contact number:		Email Address:
Highest Level of Education Completed:
Current Occupation:

Current Insurance

Do you currently have homeowners insurance? Yes No

If so, how long have you been with your current carrier?

During the past five years, have you or other occupants of the premises had a claim or loss? Yes No

Have you had a homeowners, condo or renters policy cancelled, non-renewed or declined in the past 12 months? Yes No

Property Information

Year Built	Month &Year Purchased	Type of Home	Property Occupancy	Primary Materials on Outside Walls	Material Covering Roof	Age of Roof

Replacement Cost of Home

Estimate the cost to replace your home, including attached structures. Do not include land, foundation or detached structures in your estimate.
Not sure how to estimate replacement cost of home?
(The estimate of the replacement cost of your home does not need to be precise, and we will further calculate this cost for you if you decide to purchase a policy.)
Replacement cost:

Is listed as Coverage A on your current Homeowners Policy
Is the amount of money you would have to spend to replace your home with another of like kind and quality on the same site
Does not include land and unattached buildings

Estimated Replacement Cost: ($25,000 minimum)

Property Information

Since the home was built, have any of the following been upgraded?

Electric System: Yes No

Plumbing System: Yes No

Heating and/or Cooling System: Yes No

How many people are there living in the home?

Total Number of People:

Number over the Age 18:

Number of Smokers:

Is there now, or has there ever been, an underground fuel storage tank on the property?: Yes No

Are there one or more dogs on the property?: Yes No

Prefer to talk to an agent?
Call us anytime at
630-369-0759