Value | Built | Roof |Home | A-1 Insurance Group, Inc.

Name*

First Middle Last

Date*

SINGLE or MARRIED*

Address*

Apt number/unit City State Zip Code

County*

HOME VALUE*

YEAR HOME BUILT*

SQUARE FEET*

Type of roof

HOW OLD IS ROOF*

Is the house within a 1000 ft of a fire hydrant yes or no

Yes
No

House Siding

MILES FROM FIRE HOUSE*

NAME RESPONDING FIRE DEPT*

BREAKERS or FUSES*

TYPE OF HEATING:*

PLUMBING:*

Updated Plumbing Yes or no

Yes
No

Year Done

Hidden

Updated Electrical Yes or no

Yes
No

Year Done

Hidden

AGE OF FURNACE*

TYPE OF FURNANCE*

FIRE PLACE*

TYPE OF HOME*

BRICK or FRAME*

SWIMMING POOL*

YARD FENCED*

TRAMPOLINE*

HOW MANY ACRES*

DOGS*

What Breed*

SMOKE DETECTOR*

Does the home have a sprinkler system

Yes
No

ALARM*

DEAD BOLTS*

ANY CLAIMS LAST THREE YEARS:*

DATE AND TYPE OF CLAIM

YES
NO

NUMBER BEDROOMS*

NUMBER BATHROOMS (FULL) & (HALF)*

GARAGE SIZE*

ATTACHED GARAGE*

DETACHED GARAGE*

INTERCOM SYSTEM*

SKY LIGHTS*

LIABILITY AMOUNT:*

DEDUCTIBLE AMOUNT:*

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