Please fill out the form on the previous page.
Type of Dwelling—Please choose an option—condo # unitssingle fam dwlg
Custom Home
Occupancy
When purchased?
$
Mtg?
Claims past 3 years?
Address(es)(past 3 years)
For sale or under construction?
Business on premises?
Residence Employee
Area TypeFloodingBrush HazardLandslide
Current Carrier
Cancelled/Non-renewed?
Lapse How long
Year Built
#Stories
Square Footage
GarageAttached CarDetached Car
BathroomsFullHalf
Age of Roof(In Years)
Age of Plumbing(In Years)
Age of Electric(In Years)
Heating Air(In Years)
Fire Place or Other form of heat?
Exterior Construction(Frame/Stucco..)
Interior walls
Wall ConditionsPaintWallpaperPanelling
FoundationSlabBasementCrawl Space
Please CheckPorchesPatiosBalconiesDeckSizeCoveredUncovered
Pets Or TrampolineYesNo
Feet From fire hydrant/fire station
Swimming PoolINAbove GroundJacuzziDiving BoardFenced
Alarm System/Type
Any Detached StructuresGranny FlatGazeboBLT IN BBQ
To Determine If Custom Or Semi-customMiscSkylightCeiling FansCentral VacuumWet BarFrench DoorsSliding DoorsSpecial WindowGranite or TileFloorsCrown modeling
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Comments:
Acknowledgement: I understand no coverage is bound until confirmed in writing by a KM agent
Name (type):
Date
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