Homeowner Information Update

Phone No.
Email Address
Address of Insured Property
Name	Date of Birth
- Do you Smoke?	Select One No Yes
Name	Date of Birth
- Do you Smoke?	Select One No Yes
Purchase Price	House Construction Select One Frame Brick
Year Built	No. Stories Estimated Sq. Ft. No. Baths
Roof Type	Basement Select One No Yes - Unfinished Yes - Finished
Garage Type	Select One Attached Not Attached No Garage No. Fireplaces Woodstove Select One No Yes
Primary Heat Source
Personal Auto Insurance Company
Foundation	Deck Sq. Ft. Porch Sq. Ft.
Hot Tub	Select One No Yes Trampoline Select One No Yes Swimming Pool Select One No Yes
	Diving Board or Slide Select One No Yes
No. of Dogs and Breed	Fence Type
Water	Select One Public Well Within 1000' of Fire Hydrant Select One No Yes
Within 5 Miles of Fire Dept.	Select One No Yes
Run Business on Property	Select One No Yes
Bankruptcy in Last 10 Years	Select One No Yes
Updates on Homes over 25 Years
Losses Last 5 Years