Current Homeowners Insurance Information
Company Name (not agency):
Policy Expiration Date:	Premium Amount: $
Amount Insured For:	$     Policy Type: Primary Secondary
Term:	6 Months   1 Year   Other:

Home Information
How Long At Present Address:	Year Home Was Built:
Sq. Footage (excluding garage and basement):	sq. ft.         # of Claims In Last 3 Years:

Structure Information
Type	Construction	Roof	Foundation	Garage
1 Story 1 1/2 Story 2 Story Split Level Bi-Level Other	Frame Stucco Veneer Masonry Other	Asphalt Shingle Wood Shingle Tile or Slate Other	Basement Crawl Space Slab Other	1 Car 2 Car 3 Car 4 Car None
		Age of roof: yrs.		Attached Detached Basement Built-in Car Port None

Features
Bathrooms	Basement	Deck/Porch/Patio	Fireplaces
# of Full: # of Half:	None Finished Unfinished Sq. Ft.:	Deck Sq. Ft.:     Porch Sq. Ft.:     Screened Patio Sq. Ft.:	# of Chimneys:     # of Hearths:

Additional Features
Heating System	Central Air	Central Vac	Security Alarm	Fire Alarm	Smoke Detector
None Electric Gas Oil Propane Solar Other	Yes	Yes	None Monitored Not Monitored	None Monitored Not Monitored	Yes

Please Answer the Following Questions to enable us to serve you better

Please indicate your concern regarding your current insurance protection:

Price Too Much Coverage Too Little Coverage   Insurance Company/Agency not familiar        with your business or household need

How would you rate the service that your current agent/broker provides:

Excellent   Adequate   Poor

If you could change one thing about your current insurance protection, what would it be:

Additional Comments

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