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Your 
Name:

Email
Address:

Home   Address:

Phone
Number:

Living Area Square Feet

Building
Description

Garage
Type

Number of
Bathrooms

Type of
Roof

Interior Ceiling Height

enter percent of each as it applies to your home
(total must equal 100%)

8 foot

9 foot

10 foot

Cathedral Ceilings

Post &
Beam

Home Framing

Concrete

2 X 4

2 X 6

Masonry

Exterior Walls
enter percent of each as it applies to your home
(total must equal 100%)

Aluminum/Vinyl Siding

Stucco on Frame

Brick Veneer

Asbestos Shingles

Wood Shakes

Stone Veneer

Cement Shingles

Wood Siding

Solid Brick

Solid Stone

Clapboard Redwood

Paint on Masonry

Stucco on Masonry

Clapboard Wood

Adobe

Interior Walls
enter percent of each as it applies to your home
(total must equal 100%)

Bookcase Walls

Grass Cloth Paper

Paint

Brick Facing

Imported Ceramic Tile

Sheet Paneling

Ceramic Tile

Marble

Solid Wood Paneling

Vinyl Wallpaper

Foil Wallpaper

Mirrors

Floor Covering
enter percent of each as it applies to your home
(total must equal 100%)

Brick

Hardwood

Parquet

Imported Ceramic Tile

Carpet

Slate

Custom Carpet

Laminated

Stone

Vinyl

Carpet over Hardwood

Marble

Ceramic Tile

Home Enhancements
check the box if your home
has any of the following items

Additional Furnace

Central Stereo System

Intercom System

Porch Screened

Attached Carport

Central Vacuum

Jacuzzi

Redwood Deck

Breezeway Open

Greenhouse

Metal Spiral Staircase

Solar Room

Breezeway Screened

Patio Cover

Wood Spiral Staircase

Wood Deck

Composite Deck

Hot Tub

Porch Open

Other Home
Enhancements
list the quantity of each

Atrium Doors

Greenhouse Windows

Solar Panels (Water)

Picture Windows

Atrium Windows

Solar Panels (Electric)

Bay Window

Sky Lights

Stained Glass Windows

Wet Bar

Exterior Shutters

Sliding Glass Doors

French Doors

Safety Features
Please answer
each question

Is there a central station monitored
burglar alarm?

Yes

Cooling and Heating
check the box if your home has any of the following items

Forced Air Conditioning and Heating

No

Evaporative Cooler

Masonry Chimney Fireplace

Are there deadbolt locks on all your exterior doors?

Yes

No

Metal Chimney Fireplace

Deductible

Replacement Cost
of your Contents

Replacement Cost
of your Home

Home Warranty

Mortgage
Protection

Additional Coverage Request or Questions

Yes. How much can I save?

No. Tell me more about it.

No. Tell me more about it.

No, not at this time.

Yes, I have this coverage.

Yes, I have this coverage.