Your Full Name Your Street Address City State Zip Code Township or Borough County

Daytime Phone Number Evening Phone Number What is the best time to reach you by phone? Please provide a valid email address. Telephone Email How do you prefer to be contacted?

Your occupation. For how long? Your spouses occupation. For how long?

Company Name Policy Expiration Date Annual Premium Number of claims in the pas 5 years Total paid on these claims Please provide a short description of these claims

How long at current address? If own a dog(s), list dominant breed(s). Distance to fire hydrant (in feet) Distance to fire department (in miles) No Yes Are you visible from at least 10 surrounding houses? What year was the home built? Frame Brick Home Structure

Safety Equipment

No Yes Smoke Detectors No Yes Dead Bolt Locks No Yes Fire Extinguisher No Yes Security System

If home is 20+ years old

Year roof was last updated Year central heating system was last updated Circuit Breakers Fuses Type of electrical service

Dwelling Amount Contents Amount Liability Amount

Optional Coverages

Scheduled Jewelry Other Scheduled Items No Yes Sewer and Drains No Yes Personal Liability (Umbrella)

We welcome any additional comments or requests that you may have.