Your Full Name: E-mail address to send information: Date of Birth: Spouse Full Name: Date of Birth: Street Address: City: State: Zip: County: Phone number where you would like to be contacted: Best time to reach you? AM PM Anytime Do you own your own home, or do you rent? Own Rent Is this a condominium or townhouse unit: Yes No Year of construction of home: Total square feet: Style of home: Type of garage: none 1 - Car 2 - Car 3 - Car Car - Port Is the garage attached or detached from your home? Attached Detached Is there built-in living space above the garage? Yes No Is this a normal tract home, or is it custom built? Tract Custom How many full baths? How many half baths? How many fireplaces? Roof type (I.e. wood shake, etc.): Exterior of home (I.e. stucco, etc.): Is there a burglar alarm? Local Central Station Is there a separate jacuzzi / hot tub? Yes No Wet bar? Yes No Are there fire sprinklers in the attic? Partial Full Is this a new home purchase? Yes No If yes, escrow close date: Name of current insurance carrier: Renewal date: Number of losses in the past three years: Amount paid if known: Non-smoker? Smoker Non-Smoker Are you over the age of 50? Yes No Any special riders, increased coverage limits on certain items, i.e. jewelry, fine arts etc. Are you interested in earthquake, flood and various options available? Yes No Do you have an Umbrella liability policy? Yes No Auto carrier?

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