Change of Address
*Name
*Email
*Home Phone
Work Phone
Current Property
*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
New Property
*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
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?
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
Copyright © 2003 Associated Insurance. All rights reserved.
Revised: 02/12/10