Reliable Insurance Agency

Property Information
Street
City
State
Zip
Market Value
Number of families?
Dwelling Type
What year was it built?
Construction Type
Square Footage?
Is there a Basement?	Yes No
% Finished?
Number of Bathrooms?	Full: Half:
What type of garage?
Garage size by number of cars?
Is there a Pool?	Yes No
If there is a pool, is it fenced?	Yes No
If there is a pool, is there a diving board?	Yes No
If there is a pool, is there a slide?	Yes No
Is there a smoke alarm?	Yes No
Is there a fire extinguisher?	Yes No
Are there deadbolts?	Yes No
Was the roof updated?	Yes No
If yes, what year?
Is the electrical updated?
Electrical Year
Are there circuit breakers?	Yes No
How old is the heating/ air conditioning?
Is the heating/ air conditioning thermostatically controlled?	Yes No
What is the heating energy source?
What is the heating system?
What is the cooling system?
Do you have a woodstove/woodfurnace?	Yes No
Has the plumbing been updated?	Yes No
Plumbing Year
Is the plumbing copper or plastic?	Yes No
Is there a theft alarm?	Yes No
Is there a fire alarm?	Yes No
What is the responding fire department?
What is the distance to the responding fire department?
Do you have a trampoline?	Yes No
Are there dogs on the property?	Yes No
If yes, how many and what is the breed of each dog?
Are there any other pets or animals on the property?	Yes No
If yes, how many and what is the description of each?

Current Coverage Information
What is the current insurance company?
What is the expiration date of current policy?
Were there any losses or claims in the last 5 years?	Yes No
If yes, what is the date, amount paid and description of each loss or claim?

Desired Coverage Information
Dwelling Amount	Coverage A
Other Structures	Coverage B
Personal Property	Coverage C
Loss of Use	Coverage D
Premise Liability	Coverage E
Policy Deductible	Amount
Questions or Comments
Please Note: Many insurance carriers use information gathered from you and outside sources about your claim, credit history and home. This information allows insurance companies to determine accurately the proper price to charge. You are entitled to a free copy of the reports by contacting the appropriate consumer reporting agency within the next 60 days. Please Also Note: Insurance coverage cannot be bound without a written binder from our office. By filling out this form, you agree to the above terms.