General Information

Additional Information

Are you inside or outside city limits?	Inside Outside
Distance from nearest fire hydrant	SELECT ONE less than 100 feet 100 to 500 feet 500 to 1,000 feet Not Applicable
Distance from fire department	SELECT ONE less than 1 mile 1 to 2 miles 2 to 3 miles 3 to 5 miles more than 5 miles
Age of Dwelling
Year of update: wiring
Year of update: plumbing
Year of update: heating
Year of update: roof
Amount of coverage on dwelling:	$
Liability limit	SELECT ONE $100,000 $300,000 $500,000
Replacement cost on contents?	Yes No
Deductible	SELECT ONE $100 $250 $500
Smoke detectors?	Yes No
Fire extinguisher?	Yes No
Dead bolt locks?	Yes No
Do you smoke?	Yes No
Security system?	Yes No
Woodburning equipment (stove, furnace, fireplace)?	Yes No
Any business conducted from home?	Yes No
Present carrier
Expiration date
Current premium	$