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*indicates required fields *Name *Age 55 & Retired? Yes No *E-mail *Street address *City County State *Zip Code Home Phone Work Phone FAX Purchase Price: Escrow Date :   Home Style 1 story - Ranch 1.5 story - Cape 1.65 story - Bi-level 1.75 story - Tri-level 2 story - Colonial 2 story - Victorian Standard 2 story - Victorian Ornate End Unit - Townhouse Center Unit - Townhouse Hillside Construction None Low (15-29%) Moderate (30-44%) Steep (45-60%) Type of Foundation Choose Crawl Space (built prior to 1961) Slab (built after 1961) Basement (unfinished) Basement (finished) *Garages: 1 Car        2 Cars      3+ Cars Attached  Detached  Built-In  Carport Kitchen: Standard Custom Deluxe Bathrooms: 1 1 1/2 1 3/4 2 2 1/2 2 3/4 3 3 1/2 3 3/4 4 Attached Porch: None Small Open Medium Open Large Open Small Closed Medium Closed Large Closed Attached Wood Decks: None Small Decks Medium Decks Large Decks Small Custom Medium Custom Large Custom Greenhouse: None Small Medium Large Square Footage : Year Built: Central & Alarm Systems: (Select all that apply) Smoke Alarms      Fire Extinguisher Dead Bolts             Local Fire Alarm Local Burglar Alarm Central Station Burglar Alarm Central Station Fire Alarm Finished Attic (%) : Cathedral Ceiling (%) : Breezeways: Balconies: Fireplaces:     *Current dwelling coverage: (This is not the purchase price) Liability Deductible $100,000 $300,000 $500,000 $1,000,000 $500 $1,000 $2,500 $5,000 Do you have any Jewelry, Fine Arts, Sporting Equipment or Collections which may need special "ALL RISK" Coverage? If yes, list here:   Name of Current Insurance Expiration Date *Any losses in the past 5 years? Yes No Types and dates of losses, if any   How would you like to receive your free quote? U.S.Postal E-mail Fax