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Client Information

* Required

Name *
Address of Location *
Phone Number *
Possesion/Renewal Date

Building Information

Year Built
Number of Stories
Square Footage
Deck	Yes No
if yes size
Porch	Yes No
if yes size
Sunroom	Yes No
if yes size
Garage	Yes No
	Attached Detached
# of Cars
Number of Bathrooms	Full Half
Custom Design	Yes No

Interior Flooring

% Tile
% Hardwood
% Carpet
% Vinyl
% Linoleum
Other

Plumbing

Copper
Plastic
Galvanized
Other

Electrical Service

# of Amps
Age of Furnace
Age of Roof
Finished Basement	Yes No
% Finished
Hot Tub	Yes No
Pool	Yes No
Central Air	Yes No
Fireplace	Yes No
Woodstove	Yes No
Sump Pump or Backwater Valve	Yes No

Exterior of Building

% Wood
% Brick
% Stucco
% Vinyl
Other
Additions to Building	Yes No
If yes description & size

Claims in last 3 years
Burglar Alarm
Over Age
Mortgage
Smoker