NAME:

ADDRESS:

ZIP CODE:

COUNTY:

TELEPHONE:

EMAIL ADDRESS:

SOCIAL SECURITY NUMBER:

IN CITY LIMITS: Yes No

OCCUPATION:

MARITAL STATUS: Married Single

FILED BANKRUPTCY: Yes No

ANY LOSSES? (EXPLAIN):

REPLACEMENT COST OF CONDO:

CONTENTS COVERAGE:

DESIRED DEDUCTIBLE: $250 $500 $1000 $2500 $5000

DESIRED LIABILITY LIMITS: $100,000 $300,000 $500,000

SCHEDULED ITEMS?

AGE OF CONDO?

CONSTRUCTION? Frame Brick

TYPE OF HEATING? Central/Forced Air Floor Furnace Space Heat Wood Stove

SMOKE ALARMS? Yes No

BURGLAR ALARM? Yes No

DISTANCE TO FIRE HYDRANT?(feet)

DISTANCE TO FIRE DEPARTMENT? (miles)

RESPONDING FIRE DEPARTMENT?

# OF APARTMENTS PER UNIT?

CURRENT CARRIER?

CURRENT PREMIUM?

EXPIRATION DATE?

I prefer to be contacted by: Email Phone Fax Regular Mail

Thank You for filling out our questionnaire.  We will get back to you ASAP!!!