*Name
*Email
*Home Phone		Work Phone
*Address
*City
*State	Select AL AK AZ AR CA CT CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MY MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY	*Zip Code
County home is located
Inside city limits ?	Select Yes No
Is home a new purchase?	Select Yes No
Is home currently insured?	Select Yes No	If Yes, with whom?
Any claims in the past 5 years?	Select Yes No
Owner occupied or Tenant	Select Owner Occupied Tenant
Occupation
Year built
Number of acres
Stock ponds
Any businesses on property	Select Yes No
Make of home
Sq. Footage
Number of bedrooms	Select 1 2 3 4
Number of baths	Select 1 2 3 4
*Type of Home	Select Single Family Multi-Family Condo Other
Type of Construction	Select Brick Frame Metal
Type of heating	Select Central Heat Gas Space Heaters Electric Window Unit Heat
Type of cooling	Select Cenral Air Window Unit
Wood burning stove	Select No Yes
Type of roof
Age of roof	years
Number of layers in roof	Select 1 2 3
Attached or detached garage	Select Attached Detached
Size of garage	Select 0 Car 1 Car 2 Car 3 Car 4 Car
Size of car port	Select 0 Car 1 Car 2 Car 3 Car
Any plumbing upgrades?
Any electrical upgrades?
Limits of liability	$ Select 25,000 50,000 100,000 300,000 500,000 1,000,000
Medical limits	$ Select 500 1000 2000 3000 4000 5000
Deductible limits	$ Select 250 500 1,000 2,000 1% 2%
Dwelling value	$
Contents Value	$
Replacement Cost or Actual Cash Value	$
Distance to Fire Hydrant	feet
Miles from city limits
Glass Coverage?	Select Yes No	Deadbolts	Select Yes No
Fire extinguisher	Select Yes No	Smoke alarms	Select Yes No
Swimming pool	Select Yes No	Swimming pool fenced	Select Yes No
Trampoline	Select Yes No
If pets, list type, breed and short history
If barn is present, list size, construction and use
If livestock are present, list breed and number of head
Please any equipment and description of equipment of value
Remarks

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Copyright © 2003 Associated Insurance. All rights reserved.
Revised: 02/12/10