Applicant's Name:

Mailing Address:

How do you prefer to be notified? Email Phone

Name

Phone# or

Email Address

Location of Property ( if different from above):

COVERAGES/LIMITS OF LIABILITY

Dwelling:$

Personal Liability: $500,000 $100,000 Deductible: $500 $250

ENDORSEMENTS

Jewelry $

Camera & equipment $

Computer $

Art $

Golf Equip. $

Musical Instruments $

RATING/UNDERWRITING

Frame Aluminum Siding Masonry Plastic Siding

Masonry Veneer SuperiorOther

Usage Type Primary Secondary Seasonal

Distance to Hydrant:ft.

Distance to Coast:mi.

Protection Device Type: Fire Smoke Theft Deadbolt Smoke Detector

Fire Extinguisher Occupied Daily Visible to Neighbors

Heat Type:

If Oil, where is tank?

GENERAL INFORMATION

Explain all "YES" responses in Remarks at the end of form

1. Any coverage declined, canceled or non-renewed during the last 3 years?

Yes No

2. Any losses during the last 3 years? Yes No

3. Do you own a trampoline? Yes No

4. Do you own a pool? Yes No If yes, is there a diving board? Yes No

5. Do you have a pet? Yes No If yes, what kind and breed?

6. Do you have alarms? Yes No If yes, please explain

7. Are you a smoker? Yes No

8. Date of birth Social Security #

Please explain any "YES" answers below: