Applicant Full Name
    Applicant Address
 City, State, ZipCode
Business Phone Number
    Home Phone Number 
       E-Mail Address

Are you presently insured?  Yes  No
If yes, Insurance Company:
             Renewal Date:
If no, is this a new home purchase?  Yes  No

Year house was built?

Is this a Brick or a  Frame home?

If more than 10 years old:
     1. What year were the shingles replaced?   
     2. What year was the furnace installed?  
     3. What year was the electrical system last looked at?    

What is the current market value?
What is replacement cost?        

Senior Discount: Are you over age 50?  Yes  No
                 Are you over age 55?  Yes  No

Have you had ANY loss within the last five years?  Yes  No
If yes, please list losses:
Date        Type of Loss                 Amount Paid By Ins. Co.
  
  
  

Do you have replacement coverage on your home?               Yes  No
Do you have replacement coverage on your personal contents?  Yes  No

Do you have an unrelated person living with you in your home?  Yes  No

If Yes, do you want this person's belongings (in your home)
to be covered under your policy?  Yes  No

What are your liability limits?
What is your deductible?       

Do you have any animals?  Yes  No
If yes, please list:                Has Animal Ever Bitten Anyone?
Type of Animal                                 Yes/No
           
           
           
           

Do you have a wood burning stove?  Yes  No

Do you have any of the following safety equipment?
Smoke Detector                                  Yes  No
Dead Bolt Locks                                 Yes  No
Fire Extinguisher                               Yes  No
Security System (Local Sounding Only)           Yes  No
Security System (Dials In To Security Company)  Yes  No

Credit Score: Almost all home insurance companies review an applicant's credit score when
writing a homeowner's policy. No credit score is done from this worksheet. We will quote
based upon your answer. A credit score will only be done AFTER a quote is provided, and AFTER
you agree that you would want a policy issued. Your privacy is of the greatest importance to 
us, and all information is confidential.

Please choose one:
	  a. Credit is "A1". The best possible.
	  b. I have a good credit score. 
	  c. I have an average credit score.
	  d. I have a below average credit score.
	  e. Please do not ask me about my credit score and do not consider it when
	       quoting a rate.  (will result in a higher price.)