Applicant
Information
Name:
Street
Address:
City/State/Zip:
/
/
Home Phone:
Work Phone:
Email:
Property
Information
Property
Street:
City/State/Zip:
/
/
Construction Type:
Frame
Masonry
Masonry Veneer
Vinyl Siding
Aluminum Siding
Asbestos Siding
Fire Resistant
Year Built:
Square Footage:
# Rooms:
# Apartments:
Market Value:
$
Replacement Cost:
$
Structure Type:
Dwelling
Apartment
Condo
Townhouse
Rowhouse
# Families
# Household Residents:
Is any resident a smoker?:
Select Yes/No
Yes
No
Purchase Date:
Purchase Price:
$
Distance to Hydrant:
Distance to Fire Station:
Wired Alarm
Systems
Fire Alarm?:
Yes
No
yes/no
Burglar Alarm?:
Yes
No
yes/no
Fuel:
If "Oil"
is checked, "Storage Tank Location" below is required.Storage Tank Location
Electric
Please
enter Year of Renovation, if applicable, for the
items at right.
Electrical:
Plumbing:
Heating:
Roof:
Exterior Painted:
Occupied By:
Owner
Tenant
Please
check those which apply:
Swimming
Pool?:*
Roof Type:
General
Information
Please check those
which apply.
At Home Business:
Description:
Hazard present for
flooding, brush fire, forest fire, landslide:
Description:
Animals/Pets:
Description/Breeds:
Property located within
2 miles of tidal water:
Description:
Property located on
more than 5 acres:
Description:
Trampoline
on Premises:*
Rooms,
Attics and Garages
Please
enter the quantity of each type of unit
in your home.
0
1
2
3
4
5
6
7
8
9
10
Kitchen
0
1
2
3
4
5
6
7
8
9
10
Dining
Room
0
1
2
3
4
5
6
7
8
9
10
Living
Room
0
1
2
3
4
5
6
7
8
9
10
Den/Study/Office
0
1
2
3
4
5
6
7
8
9
10
Family/Recreation
Room
0
1
2
3
4
5
6
7
8
9
10
Bedroom(s)
0
1
2
3
4
5
6
7
8
9
10
Bathrooms(s)
0
1
2
3
4
5
6
7
8
9
10
Large
Utility/Laundry/Sewing Rooms (Over 150 sq.
ft.)
0
1
2
3
4
5
6
7
8
9
10
Finished
Basement (Omit if counted as family/rec
room)
0
1
2
3
4
5
6
7
8
9
10
Attached
2-Car Garage
0
1
2
3
4
5
6
7
8
9
10
Large
Finished Attic (Over 150 sq. ft.)
0
1
2
3
4
5
6
7
8
9
10
Partially
Finished Attic
0
1
2
3
4
5
6
7
8
9
10
Partially
Finished Basement
0
1
2
3
4
5
6
7
8
9
10
Brick/Stone
Exterior Walls
0
1
2
3
4
5
6
7
8
9
10
Central
A/C
0
1
2
3
4
5
6
7
8
9
10
Aluminum/Vinyl
Siding
0
1
2
3
4
5
6
7
8
9
10
Large
Wall Fireplace
0
1
2
3
4
5
6
7
8
9
10
Enclosed
Porch/Breezeway
0
1
2
3
4
5
6
7
8
9
10
Clay
Tile or Slate Roof
0
1
2
3
4
5
6
7
8
9
10
Any
Other Unit Not Listed Here
0
1
2
3
4
5
6
7
8
9
10
Half
Bath
0
1
2
3
4
5
6
7
8
9
10
Large
Open Porch/Breezeway
0
1
2
3
4
5
6
7
8
9
10
Standard
Fireplace
0
1
2
3
4
5
6
7
8
9
10
Unfinished
Basement
0
1
2
3
4
5
6
7
8
9
10
Attached
1-Car Garage
0
1
2
3
4
5
6
7
8
9
10
Built-in
2-Car Garage/Carport
0
1
2
3
4
5
6
7
8
9
10
Small
Utility/Laundry Sewing Rooms (Under 150
sq. ft.)
0
1
2
3
4
5
6
7
8
9
10
Foyer/Entrance
Hall
0
1
2
3
4
5
6
7
8
9
10
Dressing
Room/Walk-in Closet
0
1
2
3
4
5
6
7
8
9
10
Unfinished
Attic
0
1
2
3
4
5
6
7
8
9
10
Small
Finished Attic (Less than 150 sq. ft.)
0
1
2
3
4
5
6
7
8
9
10
Mudroom
(With separate entrance)
0
1
2
3
4
5
6
7
8
9
10
Brick/Stone
Veneer (Front Wall)
0
1
2
3
4
5
6
7
8
9
10
Dinette
or Partitioned Breakfast Nook
0
1
2
3
4
5
6
7
8
9
10
Any
Other Unit Not Listed Here
General Questions/Comments:
