GENERAL INFORMATION

Name of Insured / Corporation / Property: DBA (if applicable): Mailing Address: City: State:      Zip:    Company Web site Address Any Claims / Losses YES No Reason for Request ***SELECT*** Voluntary Request Bank Required Loan Closing Is Location Insured's Principal Address ***SELECT*** Yes No

PHYSICAL LOCATIONS (if more than 5 include in Notes Section on Bottom of Page)
Address	Mkt Value	Bldg Amt.	Contents Amt.
LOC 1.
LOC 2.
LOC 3.
LOC 4.
LOC 5.

LOCATION INFO
Construction Date
Property Type	***SELECT*** Primary Residence Secondary Residence Property Rented to Others Condo/Coop
Occupancy Type	***SELECT*** Single Family Two Family Three Family Split Level Mobile Home Other (Complete Below)
Other Occupancy Type
Number of Units
Construction Type	***SELECT*** Frame Joisted Masonry Other
Basement Type	***SELECT*** Finished Unfinished Below Grade Crawl Space No Basement Other
If Basement     - Does it hold Equipment (describe)
Number of Stories
More Than 1 Building	YES No
# of Buildings
If More Than 1 Building - Distance Between?	***SELECT*** 25-100 Feet Over 100 Feet Less Than 25 Feet Other
Elevated Building	YES No
Is Garage Attached to Building	YES No
If Attached      - List Equipment or Machinery Stored

COVERAGE INFO
Contents Coverage
Contents Cvg. Deductible	***SELECT*** $500 $1,000 $2,000 $3,000 $4,000 $5,000 $10,000 $15,000 $20,000 $25,000
Building Coverage
Building Cvg. Deductible	***SELECT*** $500 $1,000 $2,000 $3,000 $4,000 $5,000 $10,000 $15,000 $20,000 $25,000
Estimated Replacement Cost

CONTACT INFORMATION

First Name: Last Name: *Email: Phone:                        Fax:    Notes / Comments: When Do You Need Quote? 24 Hrs 48 Hrs 5 Days 10 Days Other How Did You Hear About Us? Internet Print Publication Radio Friend Other