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:    

Coverage Information

Dwelling Amount $100,000 $150,000$200,000$250,000$300,000$350,000$400,000$450,000$500,000none   Personal Property $25,000 $50,000$75,000$100,000none

  Liability $500,000 $100,000$300,000$1000,000

     Deductible $500 $100$250$1,000

Contact Info

First Name:   Last Name:

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

Email:  name@jsins.com

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