Required:

Client's Name:

Address of Home:

City, State and Zip of Home Address:

Email Address:

Phone Number:

Year Built of Home:

Living Area Square Footage of Home:

If more than 40 years old, has Heating, Plumbing, Electrical and Roof been Updated?:
Yes
No

Is the Foundation of Home Built on a Slope?:
Slight
Moderate
Severe
None

Has the Home been Retrofitted?:
Yes
No

Is any Portion of the Home Built on Stilts or Pilings?:
Yes
No

Is the Home within 1000 feet of the Ocean?:
Yes
No

Is there a Monitored Alarm?:
Yes
No

Does the Home have Fire Sprinklers?:
Yes
No

Optional:

Roof Type:

Any Detached Structures on the Property:
Yes
No

Has Client Filed any Claims in Previous 3 years:
Yes
No

Any Significant Amount of Trees or Brush Surrounding the Home:
Yes
No
If yes, Approximate number of feet from Home:

Does Client have items to be scheduled (i.e. jewelry, fine arts, antiques, etc.):
Yes
No

Type of Construction:
Custom
Semi-custom
Average

Is there a Pool:
Yes
No

Is there a Trampoline:
Yes
No

Is the Home in a Gated Community:
Yes
No

Does Client own any Dogs:
Yes
No
If yes, what Breed:

Send completed form to:
Ramona Johanneson Daniel Buick Joan Bennett Linda McCarthy Lynn Sidor Cindy Pope Sandra Casey Sindy Graham Brig Denison