Risk Information

Property Address:   City: Zip:

Year Built:   Square Feet:  

# Levels: 1 2345    # Baths 1 2345     #Fireplace: 1 2345

Exterior:  Stucco Comp SidingWood SidingBrickOther    Year Painted:   

Roof Type:  TarGravel CompShingleModBidermunTileOther    Roof Age: 

Any Upgrades:  Yes No

Owner Occupied: Yes No  # Units: 0 1234   Market Value:       Loan Value:

Prior Insurance: Yes No Expiration Date:

Prior Losses/Claims: Yes No               List Claims:    

Discounts: Non Smoker  Security  Fire/Burglar Alarm  Sprinklers 50+Age  Home/Auto   Home/Auto/Life

Coverage Information

Dwelling Amount $10,000 $25,000$50,000$75,000$100,000$150,000$200,000$250,000None   Personal Property $25,000 $50,000$75,000$100,000none  

Liability Limit $500,000 $100,000$300,000$1,000,000none

     Deductible $500 $250$1,000$1,500$2,500

 Contents Replacement   Loss Association  

Type of FloaterJewelry FursArt WorkSilverware/GoldwareOther  Amount 

Contact Info

First Name:   Last Name: 

Day Telephone:   ### ### ####    Fax:  ### ### ####

Email:  name@jsins.com

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