Owners Name
Location Address
Location Address 2
Location City, State Zip	, AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY
Email Address
Contact Phone Number

Dwelling Info

Check all that apply	Occupied by named Insured Vacant In Construction For Sale
Vesting	Husband and Wife as Joint Tenants A Single Man A Single Woman As His Sole and Separate Property As Her Sole and Separate Property As Tenants in Common As to an Undivided 1/2 Interest As Community Property An Unmarried Man An Unmarried Woman As Joint Tenants			Dwelling Value
Personal Liability	100,000 300,000 500,000 1,000,000 2,000,000	Deductible	500 1,000 2,500 5,000	Medical Payments	1,000 2,500
Mo/Yr. Purchased		Sq. Ft.		Num. of Stories
Construction Type	Frame Masonry Concrete Steel Other	Year Built		Num. of Rooms
Foundation Type	Slab Raised Other	Sprinklers	Yes No	Smoke Detectors	Yes No
Pool	Yes No	Fenced	Yes No	Diving Board	Yes No
Gated Community	Yes No	Deadbolts	Yes No	Brush Area	Yes No
Num of Fireplace(s)	0 1 2 3 4 5 6 6+	Dog	Yes No	Garage Spaces	0 1 2 3 3+

Building Improvements

Fully Updated Partially Updated Year Improved Type Heating Gas Electric Electrical > Circuit Breakers Fuses Roofing > Metal Wood Shake Tar & Gravel Composite Other Plumbing Copper Galvanized PVC     Does Building have a central Alarm?  Yes No     If yes, who installed it and can you provide a certificate?

Additional Info

Mortgagee Info: Name 1   Address 1   Name 2   Address 2   Loan Number   City, State Zip   , AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY     Please list any additional info below.     ie. more than one Mortgagee, any claims made in the last 5 years, high value items.

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