Do you have collectibles: antiques, fine art, stamps, coins, etc.?

Yes No

Do you have costly sporting equipment or firearms?

Yes  No

Do you have valuable jewelry or furs?

Yes  No

Do you have valuable photography equipment?

Yes  No

Do you have a business in your home?

Yes  No

Do clients or customers come to your home?

Yes  No

Do you keep a large amount of others' business property in your home?

Yes  No

Do you have a computer in your home?

Yes  No

Do you own professional tools or equipment?

Yes  No

Do you keep samples or items for sale in your home?

Yes  No

Do you baby-sit or have child day care in your home?

Yes  No

Do you own rental or income property?

Yes  No

Are your contents covered for "replacement value"?

Yes  No

Do you have a secondary residence?

Yes  No

Do you own investment property?

Yes  No

Have you installed home fire or security alarms?

Yes  No

Do you keep more than $250 cash in your home?

Yes  No

Do you own recreational vehicles: boat, jet-ski, camper, cycle, etc.?

Yes  No

Have you remodeled your home? Have plans to do so?

Yes  No

Do you have "umbrella" liability coverage?

Yes  No

Do you have an above-ground or in-ground swimming pool?

Yes  No

Do you have detached structures: gazebos, storage barn?

Yes  No

Do you have a zipline installed on the premises?

Yes  No

Do you have pets?

Yes  No

Do you have roomers or boarders?

Yes  No

Do you have domestic help such as babysitters, landscapers, or house cleaners?

Yes  No

Do you travel frequently (domestic or foreign)?

Yes  No

Do you have a wood burning stove?

Yes  No

Do you have a fireplace?

Yes  No

Have you had your chimney professionally cleaned and inspected within the last 12 months?

Yes  No

Do you have flood insurance?

Yes  No

Is there or has there ever been evidence of water leakage or seeping in the residence?

Yes  No

Do you have earthquake insurance?

Yes  No

When was the last time you refinanced your mortgage? (mm/dd/yy)

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Are you interested in protecting yourself from identity theft?

Yes  No

Is your home insured correctly should you sustain a total loss?

Yes  No

Would you complete a residence cost estimator?

Yes  No

Full Name:

__________________________________

Street Address

__________________________________

City:

__________________________________

State:

__________________________________

Zip:

__________________________________

Phone:

__________________________________

E-mail:

__________________________________