Flood & Wind Damage

PERSONAL INFORMATION

Name

Title

Organization

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

Work Phone

Home Phone

FAX

E-mail

Web Address

Comments

   

HOME INFORMATION

Yr. of Construction:

Roof Material:

Approx House Sq Ft:

Type of Home:

Outside Walls:

Inside City Limits?

Household:

Age of Owner:

Fire Extinguisher?

Dead Bolt Locks?

Smoke Detector?

Approx loan amount?

Fireplace?

Swimming Pool?

Monitored Alarm(s)?

Satellite Dish/Antenna?

Garage Size:

# of Stories:

# of Bathrooms:

Age of Roof:

Years

 

Amount of coverage requested?    (i.e. $100,000)

Home currently insured with?    ("New" = new home)

Have you had any claims within the past three (3) years? If so, please list below.

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