Home Page Applicant first / last name Property address City State Select... AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip Code Contact: Phone daytime Contact: Phone evening Contact: Email How is the property occupied? Principal residence Seasonal residence Secondary residence Vacant or unoccupied Under construction Tenant Contents Owner Rental Policy Type Homeowner Dwelling Fire Mobile Home Dwelling Replacement Cost Liability 50,000 100,000 300,000 500,000 1,000,000 5,000,000 All Perils Deductible 100 250 500 1000 1500 2000 2500 5000 10000 Year Built Square footage Number of stories 1 1.5 2 2.5 3 4 Construction Frame Masonry Fire Resistive Masonry Veneer Aluminum Siding Vinyl Siding Stucco Semi-Fire Resistive Log Modular Other Roof Type Asphalt Shingle Composition Metal Other Aluminum Shingle Architecture Shingle Asbestos Builtup w/o Gravel Cedar Shake Cedar Shingle Clay/Slate Tile Concrete Tile Concrete Not Tile Copper Fiberglass Foam Gravel Mineral Fiber Mission Tile New England Pine Shingle Plastic Poured Recyled Roofing Product Rock Rolled Roofing Rubber Roof Seam Metal Slate Spanish Tile Corrugated Steel Steel/Porcelain Shingle Tar/Gravel Tar/Gravel Buildup Tile Tin Victorian Sclp Shingle Wood Shake/Shingle Heating System Electric Propane Natural Gas Fireplace Woodstove Other Fire Protection Class 10 9 8 7 6 5 4 3 2 1 Residence Acres Do you have any of the following breeds of dogs: Chow, Doberman, German Shepherd, Pit Bull, Rottweiler, Wolf Hybrid, or mix of these? Yes No Is any business conducted on the property? Yes No Have you experienced any losses or claims within the last 5 years? Yes No Check all of the items you are interested in covering. Fire Flood Earthquake Sinkhole Ice/Snow Wind/Hail Glass Breakage Water Damage Spoilage Pool Trampoline Livestock Computer Guns Jewelry Stamps/Coins Home Business Professional Liability Copyright Aisus.com and The Paul Long Agency © 2008

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