Desired Effective Date*
Agent* Reuben RiojasShikilia Caro
Name*
Spouse Name
Occupation
Education*
Empl. Location city
Spouse Occupation
Spouse Education
Spouse Location City
Address
In city limits YesNo
County
Mailing Address
Home Phone #
Work #
Cell #
Social Security #
Spouse SS #
Date of Birth
Spouse Date of Birth
Home purchase date
Purchase Price Of Home $
Claims in last 5 yrs YesNo
Weather related? YesNo
Theft YesNo
Water YesNo
Current Mortgage Amount $
Coverage to pay off mortgage upon death YesNo
# of yrs left on mortgage
Mortgage Company Name
Phone No
Insurance Amt $
Deductible $
Liability Amt 100k200k300k500k1MM
Effective Date of new policy
Construction Year
Construction Type FrameMasonryBoth
Foundation Type SlabCrawlBsmnt Type
Age of Roof
Type of Roof MetalAsphaltShingleOther
Updates
Roof
Electrical
Plumbing
HAVC
Heating Source
Fireplace
YesNo
Type Woodburninggaselectric
Ground floor Sqftg
Basement YesNo
Finished YesNo
Walkout U # of stories 123Bi-levelTri-level
# of baths 11.522.53
Amt of land(acres)
Own other property
Fire Depart Name
Hydrant within 500 ft 1000
Pool YesNo
Fence YesNo
Trampoline YesNo
Fence or netting YesNo
Security alarm YesNo
Local Monitored YesNo
Dogs YesNo
Breed
Bite history YesNo
Do you want coverage for Guns YesNo
Jewelry YesNo
Collections YesNo
Description
Do you want extra coverage for water back up YesNo
How did you hear about us?