PERSONAL First Name Last Name Property Address City Zip Mailing Address (if different) CONTACT Your Email (required) Personal Phone Number Work Phone Number PROPERTY DETAILS Is this your primary residence? ---YesNo What year home was built? Number of stories ---OneTwoThreeOther What year was plumbing updated? What year was wiring updated? What year was heating updated? What type of heating? If built prior to 1960, is home retrofitted for earthquakes? ---YesNo If built prior to 1960, is home bolted to the foundation? ---YesNo Is water heater braced to a wall? ---YesNo Is chimney anchored to the building? ---YesNoDoes no have chimney What is the total square footage? What is the foundation? ---Concrete SlabRaised/Crawl Space Is there a basement? ---YesNo If yes, what is the size of the basement? Is basement finished or unfinished? ---FinishedUnfinished Number of car garage? ---NoneOneTwoThreeFourOther Is garage attached or detached? ---AttachedDetached Is there a carport? ---YesNo Number of bedrooms? ---OneTwoThreeFourFiveSixSevenOther Number of full bathrooms? ---OneTwoThreeFourFiveOther Number of 3/4 bathrooms? ---OneTwoThreeFourFiveOther Number of 1/2 bathrooms? ---OneTwoThreeFourFiveOther Number of fireplaces? ---OneTwoThreeFourFiveOther Number of chimneys? ---OneTwoThreeFourFiveOther Is there central air-conditioning? ---YesNo Does the AC use the same ducts as heater? ---YesNo Size of enclosed patio (if applicable) Size of open patio (if applicable) Type of roofing ---Concrete TileClay TileComposition TileArchitectural ShinglesOther Age of roof Condition of Roof ---ExcellentGoodFairPoor Is there a pool? ---YesNo If yes, is the property fenced? ---YesNo Do you own any dogs? ---YesNo If yes, how many, what breeds, and is there a history of biting? Do you own any other property? ---YesNo If yes, how many? Are there any claims in the last five years against any of your properties? ---YesNo If yes, please describe (include date and amount paid) What percentage of flooring is wood? What percentage of flooring is carpet? What percentage of flooring is tile? What percentage of flooring is other?