Email *
Phone *
Is This a New Purchase? * Choice 1 Yes No
How Long Residing at Present Location? * Choice 1 Less Than 2 Months More Than 2 Months but Less Than 1 Year 1 - 3 Years Over 3 Years
If Less Than 3 Years, List Prior Address
Number of Insured Homeowners * Choice 1 1 2
Gender - Insured Person 1 * Choice 1 Male Female
Marital Status - Insured Person 1 * Choice 1 Single Married Domestic Partner Separated Divorced Widowed
Occupation - Insured Person 1
Level of Education - Insured Person 1 Choice 1 Less Than High School High School Some College Community or Junior College Bachelor's Degree Master's Degree PhD Law Degree Medical Degree
Are You a AAA Member? - Insured Person 1 Choice 1 Yes No
Are You an AARP Member? - Insured Person 1 Choice 1 Yes No
Gender - Insured Person 2 Choice 1 Male Female
Marital Status - Insured Person 2 Choice 1 Single Married Domestic Partner Separated Divorced Widowed
Occupation - Insured Person 2
Level of Education - Insured Person 2 Choice 1 Less Than High School High School Some College Community or Junior College Bachelor's Degree Master's Degree PhD Law Degree Medical Degree
Are You a AAA Member? - Insured Person 2 Choice 1 Yes No
Are You an AARP Member? - Insured Person 2 Choice 1 Yes No
Garage/Car Port? * Choice 1 None Garage Car Port
Garage/Car Port Size Choice 1 1 Car 2 Car 3 Car
Any Other Structures on Property? If so, Describe
Swimming Pool? * Choice 1 None Above Ground In Ground
If There is a Swimming Pool, is it Enclosed With a Fence and a Locked Gate? Choice 1 Yes No
If There is a Swimming Pool, Does it Have an Elevated Diving Board (More Than 1 Step)? Choice 1 Yes No
Trampoline? * Choice 1 Yes No
If Yes, is the Trampoline Enclosed in a Fence, Locked Gate, and surrounding net? Choice 1 Yes No
Are There Any Pets With Bite History or any Exotic, Undomesticated, or Vicious Animals On The Premises? * Choice 1 Yes No
Any Dogs? * Choice 1 Yes No
If Yes, is the Dog One of the Following Breeds? Choice 1 Rottweiler - Full Breed Rottweiler - Part Breed Doberman - Full Breed Doberman - Part Breed Pit Bull (All Variants) - Full Breed Pit Bull (All Variants) - Part Breed Akita - Full Breed Akita - Part Breed Husky/Malamute - Full Breed Husky/Malamute - Part Breed Chow - Full Breed Chow - Part Breed German Shepherd - Full Breed German Shepherd - Part Breed Presa Canarios - Full Breed Presa Canarios - Part Breed Great Dane - Full Breed Great Dane - Part Breed No
Any Farm Animals? * Choice 1 Yes No
Are There any Business Pursuits Being Conducted on the Premise? * Choice 1 Yes No
Smoke Detectors? * Choice 1 Yes No
What Kind of Alarm Do You Have? * Choice 1 None Local Fire Local Burglary Local Fire and Burglary Central Fire Central Burglary Central Fire and Burglary
Is Mobile Home Located 5 Miles or Less From the Primary Responding Fire Department? * Choice 1 Yes No
Who is the Primary Responding Fire Department?
Is Mobile Home Within 1,00 Feet of a Fire Hydrant? * Choice 1 Yes No
Any Losses or Claims in the Last 5 Years? * Choice 1 Yes No
If Yes, Please List the Dates and a Brief Explanation of Each Claim or Loss