Home Owner Quote by slesueur | Mar 24, 2020 Web Site Name (First, Last) Have you had a bankruptcy? Yes No If so, how long ago? Location Deeded name on property same as insured Yes No If no, who owns the home? Miles to Fire Dept? Feet to Hydrant? Construction of Dwelling Yr Built? # of Stories A/C Fireplace Pool? If so, diving board? If so, is the pool fenced? Today's Date Phone # * Address Street #, Street, CIty, State, Zip His Information - DOB His SS# Her DOB Her SS# Purchase price Occupancy If new purchase, prior address? Square Footage # of Baths Roof Type Trampoline? Primary Heat Source Animals? If dog, any biting history? Occupation His Occupation Her Occupation Prior Insurance Claims in past 3 years Employer Employer Company Detail What number did you dial to reach us?