Homeowner/Renter Information
First Name:    Last Name:    Email Address:

DOB: SSN:

Street Address:
Address:   Address 2:   City:   State:
Mailing Address:
Address:   Address 2:   City:   State:
Residence in city limits: If not in city limits, How far from city limits?:
Number of Losses:
Year Built:
Dwelling Type:
Homeowner
Condo/Town house
LandlordProtector
Renter
Moble home
Dwelling Fire

Consturction Type:
Adobe
Frame with < 33 % Veneer
Frame with < 66 % Veneer
Frame with < 100 % Veneer
Masonry/Brick
Wood Sliding Over Frame

Style Code:
Single Story
1 & 1/2 Story
2 Story
Bi-Level/Raised Ranch
Modular
Split Level
Townhome (end unit)
Townhome (mid unit)

Interior Code:
1 = 100% paint and 95% carpet
2 = 75% paint and 90% carpet
3 = 50% paint and 50% carpet
4 = 35% paint and 40% carpet

Basement % of ground floor:
Basement % finished:
Square Footage:
Number of Units:
Roof Type:
Asphalt/Shingle
Asphalt/Fiberglass
Concrete/Cement
Spanish Tile
Woodshake
Other

Discounts
Non-Smoker
Security
Central Alarm
Local Burgelar Alarm
Local Fire Alarm
Sprinkler
Year Renovated:

Garage Type:
Carport
Detached
Attached 1 Car
Attached 2 Car
Attached 3 Car
Built-in 1 Car
Built-in 2 Car
Built-in 3 Car

Kitchen Grade:
Economy
Standard
Custom
Luxuary

Interior Walls:
Dry Wall
Plaster
Exterior Walls: (Give % of each. Should equal 100%)
Wood Siding
Stone Veneer
Solid Stone
Painted Masonry
Aliuminum Siding
Stucco On Frame
Stucco On Masonry
Brick Veneer
Solid Brick
# of Full Baths:
Economy
Standard
Custom
Luxary
# of Half Baths:
Economy
Standard
Custom
Luxary
Number of Fireplaces:
Additional Features:
Stained Glass
Ornamental Stairs
laundry Tub
Additional Furnace
Spiral Staircase
Jacuzzi
Indoor BBQ
Trash Compactor
Solar Panels
Intercom
Sauna
Skylights
Wet Bars
Interior Shutters
Exterior Shutters
Garage Opener
Deductible:
500
750
1000
1500
2500
Message:



©2005, DNA Web Design