HOMEOWNERS
Insureds Name:
Street Address:
City, State, & Zip:
County:
Occupancy:			Select Owner Occupied - Primary Residence Owner Occupied - Secondary Residence Tenant Occupied
Type of Building:			Select Single Family Dwelling Two Family Dwelling Three Family Dwelling Four Family Dwelling
Is this a Row Home with Flat Roof:					Select Yes No
Is the building currently under renovation:					Select Yes No
Policy Type:			HO-3 HO-6
Policy Term:			12 Months 6 Months 3 Months
Wind Coverage:			Select Included Excluded
AOP Deductible:			Select 500 1,000 2,500 5,000 10,000
Named Storm Deduct:			Select 0 1% 2% 3% 4% 5%
Wind / Hail Deductible:			Select 500 1,000 2,500 5,000 10,000
Dwelling Value:
Other Structures:
Personal Effects:
Loss of Use:
Liability Limits:			Select None 25,000 50,000 100,000 300,000 500,000 1,000,000
Medical Payments:			Select None 5,000 6,000 7,000 8,000 9,000
Personal Injury:			Select Yes No
Distance to Ocean:			Select Less than 1 mile 1 to 5 miles 5 miles or more
Protection Class:			Select 1 2 3 4 5 6 7 8 9
Year Built:
Construction:			Select Frame Steel Metal Brick Veneer Joisted Masonry Stucco Masonry Brick Stone
Have full updates been made to the					If yes,
following in the past 10 years:					what year:
	Wiring:			Yes No
	Plumbing:			Yes No
	Heating:			Yes No
	Type of Heat:			Select Oil Natural Gas Electric Other
	Roofing:			Yes No
	Central Burglar Alarm:			Yes No
	Central Fire Alarm:			Yes No
	Gated Community:			Yes No
Optional Coverages:
Replacement Cost on Home:				Yes No
Replacement Cost on Contents:				Yes No
Extended Replacement Cost				Yes No
	(125% of Coverage A)
Animal Exclusion Buy Back:				Yes No
If Yes, Advise Breed & Bite History:
Earthquake:				Yes No
Earthquake Deductible:				N/A 1% 2% 5% 10%
Increased Law & Ordinance:				Yes No
Water and Sewage Backup:				Select None 5,000 10,000 15,000
Mold Sublimit:				Select None 5,000 10,000 15,000
Mens Jewelry Limit:
Ladies Jewelry Limit:
Furs:
Silver:
Golfing Items:
Fine Arts:
Guns:
Any Claims past 3 Years:				Yes No
If claims, please provide details:
Agency Name:
Agency Address:
Agency Phone:
Agency Fax:
Agency Contact:
Contact E-Mail Address:
Any other information you would like us to know about this risk:
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								(Version 2)