Phone *
Email *
Number of Years at Current Address *
If Less Than 3 Years, List Prior Address
Number of People Insured * 1 2
Gender - Insured Person 1 Male Female
Marital Status - Insured Person 1 * Single Married Domestic Partner Separated Divorced Widowed
Occupation - Insured Person 1
Level of Education - Insured Person 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 Yes No
Are You an AARP Member? - Insured Person 1 Yes No
Gender - Insured Person 2 Male Female
Marital Status - Insured Person 2 Single Married Domestic Partner Separated Divorced Widowed
Social Security Number - Insured Person 2
Occupation - Insured Person 2
Level of Education - Insured Person 2 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 Yes No
Are You an AARP Member? - Insured Person 2 Yes No
Year Built
Construction Type * Masonry Veneer Frame Vinyl Siding Log Other
Members in Household *
Number of Units in Building *
Square Feet
Number of Stories in Building *
Floor unit is located on? *
Type of Foundation
Number of Bathrooms *
What Type of Roof? Asphalt/Composition Shingles Metal Other
Primary Heat Type None Gas Oil Electric Geo Thermal
Auxiliary Heat Type None Gas Oil Electric Geo Thermal
Swimming Pool? * None Above Ground In Ground
If There is a Swimming Pool, is it Enclosed With a Fence and a Locked Gate? Yes No
If There is a Swimming Pool, Does it Have an Elevated Diving Board (More Than 1 Step)? Yes No
Trampoline? * Yes No
If Yes, is the Trampoline Enclosed in a Fence, Locked Gate, and surrounding net? Yes No
Smoke Detectors * Yes No
Fire Extinguishers * First Choice Yes No
Couldn't Read this one????
Security Alarms? If so, what type? * First Choice No Alarm Central Alarm Local Alarm
Personal Property Coverage Amount
Personal Liability $100,000 $200,000 $300,000 $400,000 $500,000
Medical $1,000 $2,000 $5,000
Deductible $500 $1,000 $1,500 $2,000 $2,500 $5,000
Replacement Costs Yes No
Any Losses or Claims in the Last 5 Years? * Yes No
If Yes, Please List the Dates and a Brief Explanation of Each Claim or Loss
