First Name
Last Name
Address - Line 1
Address - Line 2
City
State
Zip Code
Date of Birth
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
Amount of coverage desired on dwelling
Deductable Desired
Construction Type
Single Family or Duplex?
Year Built
Fire place
Yes
No
Wood Burning Stove
Yes
No
Responding Fire Department
Miles from Fire Department
Hydrant within 100 feet
Yes
No
Inside/Outside City Limits
Smoke Detectors
Yes
No
Number of Stories
Garage
Yes
No
Attached / Detatched
Attached
Detatched
Approximate Square Footage (not including basement)
Number of Cars
Basement
Yes
No
Finished
Yes
No
Walkout Basement
Yes
No
Central Air
Yes
No
Deck/Porch (Enclosed Porch)
Yes
No
Square Footage (of Deck or Porch)
Number of Full Bathrooms
Number of Half Bathrooms
Anyone in household a member of professional society, credit union, alumni association, etc? If yes, which one(s):
AARP Member
Yes
No
Occupation
Security System
Yes
No
Monitored
Yes
No
Phone or Mail Proposal
Phone Number
Email
Any claims in the past 3 years?
(If yes, please indicate date of loss, amount paid, and description of claim)
Copyright Hartman Insurance Agency Inc., 2010
