Name: (First and Last)

Birth date:

2nd Name:

2nd Birth date:

Married?  Yes No

E-Mail Address:

Phone Number:

Address to be insured:

               City and Zip

GA

               County

Address prior to moving to Address being Insured:

               City and Zip

               County

 Renter’s Insurance Property Coverage amount:

$15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 None

Renter’s Deductible

$1,000.00 $500.00

Homeowner’s deductible: $500.00 $1,000.00 $2,500.00 $5,000.00

Liability Level: Option 1 & 2

$100,000.00 $200,000.00 $300,000.00 $500,000.00

$300,000.00 $100,000.00 $200,000.00 $500,000.00

Is there a Mandatory Homeowner Association?

YES

NO

Basement? % finished?

Slab Crawl Space Partial Basement Full Basement

0% Finished 25% Finished 50% Finished 75% Finished Full Finished

# of Full Baths and Half Baths:

1 Full Bath 2 Full Baths 3 Full Baths 4 Full Baths 5 Full Baths 6 Full Baths 7 Full Baths

NONE 1 Half Baths 2 Half Baths 3 Half Baths 4 Half Baths

# of “stories”:

Ranch-Single Story Bi-Level / Split Foyer 2 Story 3 Story Tri-Level

The basement does not count as a “floor” or Story.

Year built — Square Feet

Garage — Location

NONE 1 Car Garage 2 Car Garage 3 Car Garage 4 Car Garage 1 Car Carport 2 Car Carport

In Basement Attached-Living Space Above Attached-NoLivingSpaceAbove Detached-NoLivingSpace Detached-withLivingSpace NONE

Fireplace:

NONE 1 Fireplace 2 Fireplaces 3 Fireplaces 4 Fireplaces

Anticipated Closing Date:

Exterior Construction:

Wood Siding Brick Vaneer Hardi-Plank Stucco Other-Siding Log

Roof Construction:

Asphalt Shingles Tile Metal Flat Rubber

Anticipated Move-In Date:

Flooring

Carpet Hardwood Tile Vinyl Stone

Vinyl Hardwood Carpet Tile Marble Other

Heating and A/C

Central Heat Central Heat OIL Central Heat Propane NONE Other-comment below

Central AC Window AC NONE Other-Comment Below

Type of Home:

Single Family Townhome-EndUnit Town Home-Interior Unit

Comments/Remarks:

As part of the application process, we may collect personal information from persons other than you or other individuals proposed for coverage, including credit reports and loss information reports. This information, as well as other personal or privileged information subsequently collected by us, may in certain circumstances be disclosed to third parties without your authorization. You have a right of access and correction with respect to all personal information we collect. If you would like more detailed information in writing about our information collection practices, please let us know.

NOTE: In regard to the statement above, we are required to post this as a process of obtaining Loss Information History and final quoting criteria.  Submitting this form approves the collection of data.  We have not asked for and do not require a social security number in this process.

Choosing Submit is also Acceptance of the information noted above: