Tell us about your current coverage...     Insurance Company         Annual Premium         Current Dwelling Amount         Any Claims in the past 3 years     Yes    No

Tell us about your home...     Years at this home         Year Built         Current Market Value         Construction Type         Total Square Footage         Number of Stories         Basement, Crawl Space or Slab?     Select... Basement Crawl Space Slab     Finished Basement?         Fireplace?         Central Air Conditioning?         Number of Full Baths:     Number of 1/2 Baths:     Select... 1 2 3 4 5 6     Select... 1 2 3 4     Attached or Detached Garage?     # of cars?     Select... Detached Attached     Select... 1 2 3 4 5 6     Wood Stove?     Trampoline?     Yes    No     Yes    No

Do you qualify for the following discounts...     Alarm System Type?         Non-Smoker?     Yes    No