Homeowners Insurance

Property Type:	-Select- Single Family Duplex Multi Family Townhome Condominium Mobile Home	Built Year:	YYYY 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908
Occupancy:	-Select- Primary Residence Multi Family Vacational Tenants Occupied	Stories:	-Select- 1 1 1/2 2 2 1/2 3 Bi-Level Tri-Level
Garage:	-Select- No Garage Carport Attached - 1 Car Attached - 2 Cars Attached - 3 Cars Not Attached - 1 Car Not Attached - 2 Cars Not Attached - 3 Cars Other	Beds/Baths:	-Select- 1 Bed 2 Beds 3 Beds 4 Beds 5 Beds 6 Beds 7 Beds 8 Beds 9 Beds / -Select- 1 Bath 2 Baths 3 Baths 4 Baths 5 Baths 6 Baths 7 Baths 8 Baths 9 Baths
Foundation:	-Select- Basement Open (Cement Non-Solid) Slab (Cement Solid) Piers Pilings Stilts Other	Fireplace:	Yes No
Security System:	-Select- No alarm Alarm sounds in home only Signals monitoring company	Square Footage:	-Select- 500 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 2400 2500 2600 2700 2800 2900 3000 3100 3200 3300 3400 3500 3600 3700 3800 3900 4000 4100 4200 4300 4400 4500 4600 4700 5000+
Your Credit History:	-Select- Poor Average Good Excellent	Dwelling Value:	-Select- $50000 $75000 $100000 $125000 $150000 $175000 $200000 $225000 $250000 $275000 $300000 $325000 $350000 $375000 $400000 $425000 $450000 $475000 $500000 $525000 $550000 $575000 $600000 $625000 $650000 $675000 $700000 $725000 $750000 $775000 $800000 $825000 $850000 $875000 $900000 $925000 $950000 $975000 $1000000 $1250000 $1500000 $1750000 $2000000 $2250000 $2500000 $2750000 $3000000 $3250000 $3500000 $3750000 $4000000 $4250000 $4500000 $4750000 $5000000

Is this a newly purchased property (within the last 3 months)?	Yes No
Are you currently insured or have been insured for the last 30 days?	Yes No
Have you filed any homeowners insurance claims in the last 3 years?	None 1 2 3 4 5

Construction Class:	-Select- Standard Luxury Economical Manufactured	Roof Type:	-Select- Asphalt Shingle (Common) Composition Shingle Wood Shingle Tile Shingle Metal Roof Flat Roof Other
Construction Type:	-Select- Wood Frame Metal Frame Masonry Log Home Other	Exterior Walls:	-Select- Mostly Brick Mostly Wood Frame Mostly Stone Aluminum Siding Vinyl Siding Veneer Cinder Block Stucco Other
Service Panel:	-Select- Circuit Breaker Fuse Box Other Unknown	Heating Type:	-Select- Gas Forced Air Boiler Oil Propane Electric Stove Other Unknown
Proximity to Water:	-Select- Not Applicable Within 1000 feet Within 1 mile Within 5 miles	Wiring Type:	-Select- Copper Aluminum Knob and Tube Unknown
Dog:	Yes No	Current Carrier:	Select TOP COMPANIES AAA AIG / American General Allied Allstate American Family Amica Blue Cross / Blue Shield Farm Bureau/Farm Family/Rural Farmers GEICO GMAC Liberty Mutual Nationwide Progressive SAFECO State Farm The Hartford Travelers Unitrin Direct USAA MORE COMPANIES AETNA AFLAC AIU Insurance American Alliance Insurance American Automobile Insurance American Casualty American Deposit Insurance American Direct Business Insurance American Empire Insurance American Financial American Home Assurance American Insurance American International Insurance American Manufacturers American Mayflower Insurance American Motorists Insurance American National American Premier Insurance American Protection Insurance American Republic American Savers Plan American Service Insurance American Skyline Insurance American Spirit Insurance American Standard Insurance Arbella Associated Indemnity Assurant Atlanta Casualty Atlantic Indemnity Auto Club Insurance Company Cal Farm Insurance California State Automobile Association Chubb Clarendon American Insurance Clarendon National Insurance CNA Colonial Insurance Continental Casualty Continental Divide Insurance Continental Insurance Cotton States Country Insurance Dairyland Insurance Electric Erie Esurance Farmers Union Firemans Fund Foremost Golden Rule Government Employees Insurance Guaranty National Insurance Hanover Health Plus of America HealthMarkets HealthShare America Humana IFA Auto Insurance IGF Insurance Infinity InsuranceConstruction Class: Roof Type: Construction Type: Exterior Walls: Infinity National Insurance Infinity Select Insurance Integon John Hancock Kaiser Permanente Kemper Landmark American Insurance Leader National Insurance colspan="3" Leader Preferred Insurance Leader Specialty Insurance Liberty Insurance Corp Liberty National Liberty Northwest Insurance Lumbermens Mutual Maryland Casualty Mass Mutual Mega / Midwest Mercury MetLife Auto and Home Metropolitan Mid Century Insurance Mid-Continent Casualty Middlesex Insurance Midland National Life Mutual of New York Mutual Of Omaha National Ben Franklin Insurance National Casualty National Continental Insurance National Fire Insurance National Health Insurance National Indemnity National Union Fire Insurance New York Life Northwestern Mutual Life Northwestern Pacific Indemnity Omni Insurance Orion Insurance Pacific Insurance Pafco General Insurance Patriot General Insurance Peak Property and Casualty Insurance PEMCO Pennsylvania life Prudential Reliance Insurance Republic Indemnity Response Safeway Insurance SBLI Security Insurance Sentinel Insurance Sentry Shelter St. Paul Standard Fire Insurance Company State and County Mutual Fire Insurance State National Insurance Superior American Insurance Superior Guaranty Insurance Superior Insurance The Ahbe Group TICO Insurance TIG Countrywide Insurance Tri-State Consumer Insurance Twin City Fire Insurance UniCare United American/Farm and Ranch United Pacific Insurance United Security United Services Automobile Association Universal Underwriters Insurance US Financial USF and G Viking Insurance Windsor Insurance Woodlands Financial Group Zurich North America (Not Listed)
Major Upgrades Year:	YYYY 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908	Current Policy Expires:	MM Jan Feb mar Apr May Jun Jul Aug Sep Oct Nov Dec DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908
Coverage Type:	-Select- Full Package Fire and Liability Liability Only	Current Residence:	-Select- Less than 1 year 1 year 2 years 3 years 4 years 5+ years
Liability Protection:	-Select- $100,000 $300,000 $500,000 $1,000,000 (Umbrella) $5,000,000 (Umbrella)	Previous Residence:	-Select- Less than 1 year 1 year 2 years 3 years 4 years 5+ years
Deductible:	-Select- $100 $250 $500 $1,000 $2,500	Applicant's Birthdate:	MM Jan Feb mar Apr May Jun Jul Aug Sep Oct Nov Dec DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908

Checkmark what applies to the property

Deadbolt Locks	Smoke Alarm	Fire Extinguisher(s)
Manned Fire Station (within 5 miles)	Fire Hydrant (within 1,000 feet)	Indoor Sprinklers
Copper Water Pipes	Brush Hazard (within 500 feet)	Flood Area
Central Air Conditioning	Sauna	Hot Tub
Woodburning Stove	Sump Pump	In-Ground Swimming Pool
Swimming Pool is Fenced	Smoker in Household

First Name:
Last Name:
Street Address:
Zip Code:
Day Phone:
Cellphone:
Best Time to Contact:	Morning Afternoon Evening
Best Telephone Number To Reach You At:	Home Cell
Email:
Social Security Number:

Provide all the claims you have filed in the last 3 years

	Date of Claim	Type of Claim	Amount Paid	Comments
Claim 1:	MM Jan Feb mar Apr May Jun Jul Aug Sep Oct Nov Dec DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908	-Select- Weather Theft Vandalism Fire Water Other
Claim 2:	MM Jan Feb mar Apr May Jun Jul Aug Sep Oct Nov Dec DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908	-Select- Weather Theft Vandalism Fire Water Other
Claim 3:	MM Jan Feb mar Apr May Jun Jul Aug Sep Oct Nov Dec DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908	-Select- Weather Theft Vandalism Fire Water Other
Claim 4:	MM Jan Feb mar Apr May Jun Jul Aug Sep Oct Nov Dec DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908	-Select- Weather Theft Vandalism Fire Water Other
Claim 5:	MM Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927