Name Address City State  Zip Work Phone Home Phone E-mail Present Home Insurance Co. Home Now Insured For Date Home Insurance Expires How long at present job? Occupation How long at present address? Number of claims in last 3 years? Square footage of home excluding garage and basement? Year home was built?  TYPE CONSTRUCTION FOUNDATION ROOF 1-Story 1 1/2-Story 2-Story Split Level Bi-Level Frame or Stucco Masonry Veneer Masonry Basement Crawl Space Slab Asphalt Shingle Wood Shingle Tile or Slate Other Age of Roof GARAGE BATHROOMS OTHER FEATURES 1-Car 2-Car 3-Car 4-Car Attached Detached Basement Built-in Car Port # of Full # of Half  Central Air Cond.    Central Vacuum    Security System    Wet Bar    Whirlpool Tub   FIREPLACES BASEMENT DECK, PORCH, PATIO # of Chimneys   # of Hearths   Finished  Yes No Sq. Ft. Deck sq. ft. Porch sq. ft. Screened Patio sq. ft.