GENERAL CLIENT INFORMATION

DWELLING Ã¢â¬â COVERAGE A

Location Address (if different from mailing):

Residence Square Footage:

Number of Full Baths:

Number of Half Baths:

Construction Type: Wood Frame Masonry Veneer Masonry

Type of Heating: Electric Natural Gas LPG Fuel Oil Wood Solar

Year of last update:

Is there a Fireplace?: Yes No

Central Burglar Alarm?: Yes No

Inside sprinkler system?: Yes No

Others in Household:

ADDITIONAL STRUCTURES Ã¢â¬â COVERAGE B

Describe all Structures at the same address that are not attached to the residence

Does the insured employ domestic help? Yes No

List the name of each individual, their duties, if he or she live on premises and number of hours he or she works per week.

Live on Premises Yes No

Jewelry in Excess of $1,500?: Yes No

Unusual Items that should be scheduled?: Yes No

Does the insured own other dwellings? Yes No

Number of Secondary Homes:

How many are tenant occupied?:

PERSONAL LIABILITY

List all animals kept at the primary residence.

Are there any outdoor:

Swimming Pools: Yes No

What are the occupations of all insured individuals?

Does the insured own vacant land? Yes No

If yes, List the location of the vacant land and the acreage.

PERSONAL UMBRELLA

Name(s) of Operator(s)

Vin # (if available)

Are any of the vehicles considered antique or classic cars? Yes No

If yes, which vehicle and how many miles is it driven annually, how is it used and describe the restoration and customization?

RECREATIONAL VEHICLES

List all owned or leased recreational vehicles Ã¢â¬â licensed and unlicensed. This includes but is not limited to trailers, campers, motorcycles, all-terrain vehicles, dune buggies, race cars and similar motorized vehicles.

List all owned watercraft.

Where does the watercraft operate Fresh Water Salt Water

What is the lay-up period of time?

Where is the watercraft stored during lay-up?

Is the watercraft taken outside United States territorial waters? Yes No