Home Owner Quote Request From
Basic Information:	Effective Date Exipration Date
Insured's Name:			Ph:
Email Addres:
Adress:		City:	Zip:
Dwelling Value		Year Built:	Number of Units:
Occupency / Usage		Total Square Foot:	Numer of Stories:
Construction Type	MasonryVeneerWood frame	Distance to Hydrant:
Roof Type	AsphaltCompositionHail ResitantTilesWood Shingles
Home Alert Protection	NoneBurglary AlarmFire AlarmBurglary & Fire Alarm
Number of	Fireplaces Bedrooms Bathrooms Pools Patio
Distance of Fire Station	miles	Age of roof yrs (if different from dwelling)
Plumbing	CopperGalvanizedPVCBurglary & Fire AlarmOther		Age of Plumbing yrs
Prior Losses (Last 5 year)	No prior Losses1 Non-Theft Loss1 Theft or 2 Non-Theft
Have an existing FAIR Plan Policy:	YesNo
	less then 500 ft Brush ClearanceLocated in state forestLocated in Forested Area
Closed Escrown within 60days?	YesNo
Deadbolts on all Exterior Doors	YesNo	Less than 3" setbacks? YesNo
Full fucntional Fire Extinguisher	YesNo	Smoke Alarms: YesNo
Community	RetiredGatedOtherNone	Any Pets?YesNo   How many?
Is there a garage?	AttachedDeatachedNo Garage	Number of Car Garage: 12
Does the Dwelling  have fuses providing power to any portion of the dwelling?YesNo