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Name: Address: City:  State: SC  Zip: Home Phone*: Work Phone: E-mail*: Date of Birth: Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec. 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 Marital Status: married single divorced widowed Present Home Insurance Company: Expiration Date: Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec. 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 (year xxxx) Preferred method of contact: home phone work phone email Coverage Amount: Deductible Amount: 250 500 1,000 Liability Amount: 100,000 300,000 500,000 Responding fire dept.: Fire Hydrant within 1000ft: yes no The year house was built: Heated Square Footage: Claims filed in last 3 years: 0 1 2 3 4 5 or more Type of Home: 1 Story 2 Story Split Level Other Construction Type: Frame Brick Stucco Vinyl Foundation Type: Finished Basement Unfinished Basement Slab Crawl Space Age of Roof: 0 - 5 years 5 - 10 years 10 - 15 years 15 - 20 years over 20 Garage Type: Single Double Carport None Other Number of bedrooms: 1 2 3 4 5 more than 5 Number of bathrooms: 1 2 3 4 5 more than 5 Heating Type: Cooling Type: Security System: none smoke alarm local fire alarm central station alarm Comments:

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