Homeowners/Dwelling Fire

Address (mailing and physical)

Phone Number

Email Address (if available)

Age of Insured

Location to be Insured:  street, city, parish

Brick or Frame?

Owner or Tenant Occupied?

Year Built?

Total Square Footage?

Type of Heating?

Carport or Garage?  (also number of cars)

Number of Bathrooms?

Type of Coverage (homeowners? dwelling fire?)

Amount of Coverage?

Prior Insurance Company?

When does current policy expire?

Prior Loses of Claims (list type and when loss occurred)

Do you have any of the following:

• trampoline?

• dogs? (if yes, what type)

• cattle?

• swimming pool? (if yes, is it fenced with a lock and gate?)