HOMEOWNER CHECKLIST
Date of Contact:
Name:
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Home Telephone:
Work Telephone:
Cellphone:
Date of Birth:
Prior Insurance Company:
Claims in Last Three Years:
Year Built:
# of Stories :
Sq. Feet Main:
Structure:
Finished Basement:
Yes
No What %:
Frame or Masonry:
Fireplace:
Yes
No
Number of Baths:
Wood-buring Stove:
Yes
No
Central Air:
Yes
No Any Pets:
Garage:
Yes
No # of Cars:
Attached of Detached:
Outbuildings:
Recreational Vehicles:
Porch:
Yes
No Type of Porch:
Sq. Feet:
Updates:
Roof
Wiring
Plumbing
Heating
Liability Amount:
Ext. of Liability:
Any new additions or updates to your home:
Additional Coverages
Replacement Cost on Contents:
Yes
No
Water Sewer Backup:
Yes
No Amount:
Earthquake:
Yes
No Anything else of Value:
Jewlery:
Yes
No Amount:
Boat:
Yes
No
Discounts:
Alarm
Dead Bolt Locks
Fire Ext.
Smoke Alarms:
