Date:  
     
  First Last
Name:
     
  Street  
Address:
  City State Zip
 
     
E-Mail:
     
  Home Work
Phone Number(s):
  Mobile Fax
 
     
E/W of 95:  
     
E/W Interco:  
     

Homeowner Occupied:
Length of Occupancy:
Rental: Yes   No
Losses?
If Losses, Describe:
   
Below information needed for homes not lived in all year-round:
Seasonal: Yes   No
Secondary: Yes   No
Central Alarm: Yes   No
If Not, Not Eligible, Except JUA  
   
Building Information
   
Age of Building:
Construction Type:
Floors:
Roof Type:
Date Roof Updated:
Date Wiring and Plumbing Updated:
Circuit Breakers: Yes   No
Central Air: Yes   No
Square Footage of Building:
Bedrooms:
Baths:
Pool: Yes   No
Fence Type:
Pets: Yes   No
On Water: Yes   No
Central Alarm:   Fire   Burglary
Distance To: Fire Station   Hydrant
Deadbolts: Yes   No
Fire Extinguisher: Yes   No
Smoke Alarm: Yes   No
Sliding Doors: Yes   No
Shutters/Impact Windows: Yes   No
Value of House:
   
   
Condominium
   
Condo Name:
Number of Floors:
Ins. Floor Number:
Condo Value: Additions/Alterations
Number of Buildings:
Personal Property Value:
Flood: Yes   No
   


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