Risk Information

Property Address: City:  Zip:

Year Built:   Square Feet:

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

Exterior:  Stucco Comp SidingWood SidingBrick Other    Year Painted:   

Roof Type:  TarGravel CompShingleModBidermunTile Other    Roof Age: 

Any Upgrades:  Yes No

# Units: 0 1234    Market Value:       Loan Value:

Owner Occupied: Yes No   Owner's Age:    less than 50 50-55 56-60 61-65 over 65   Owner's Occ Other Accountant/CPA Architect Doctor Educator Engineer Fireman Judge Lawyer Nurse Police Realtor Scientist Student

Prior Insurance: Yes No  Expiration Date:

Coverage Information

Dwelling Amount $100,000 $150,000$200,000$250,000$300,000$350,000$400,000$450,000$500,000 $600,000 $750,000 $900,000 none  Liability Limit $500,000 $100,000$300,000$1,000,000none

     Deductible $500 $250$1,000$1,500$2,500 $3000 $5000

Extended Repl   Code Upgrade  Contents Repl

Type of FloaterJewelry FursArt WorkSilverware/GoldwareOther Amount 

Contact Info

First Name:   Last Name: 

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

Email:  name@jsins.com