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HOMEOWNERS INFORMATION REQUEST
  Todays Date:
 
PERSONAL INFORMATION
  Name: D.O.B. S.S.# Employer:
  Name: D.O.B. S.S.# Employer:
  Home Ph: Work Ph: Address:
  City State: ZIP:
  Buying Now? Yes No          Vacant Now? Yes No          Families On Site Single Multi
   

 
HOME INFORMATION
  Year home was built: Square Footage:
  Roof Composition Metal Tile   Other: Age / Yrs: #Stories: Foundation Slab P&B
  Construction Brick Frame Brick Veneer Other: All Sides: Yes No  Percentage:
  ----
  Mobile Manufactured Home? Site Built Manufactured Home?   Model# Park:
  Mobile/Mfg Home Year of Manufacture   Make   Serial#   Length:   Width:
  Mobile/Mfg Home Original Purchase Price:     Date of Purchase:
  ----
  #Bathrooms:   #Bedrooms:   Total # Rooms in Home :     Auto Garage Carport Attached Detatched  # Spaces:
Heat / AC Central Wall Unit[s]   +Gas?     Carbon Monoxide Detector? Yes No  Fireplace[s?] Yes No  Total # :  
  Stove Standing? Yes No       Cook Top & Built In Oven? Yes No      Dishwasher? Yes No       Ceiling Fans? Yes No
   
 
  Other Amenities  
Basement   Deck   Trampoline   Pool   4'Fence   Self Locking Gate [Required for Pool or Trampoline]
Dogs on premises? Yes No         If Yes, what breed[s]?

   
  FIRE PREVENTION
  Inside the City limits? Yes No         If not, is there a fire hydrant within  1000 feet of the property? Yes No 
  Is there a fire department within 5 miles of the property? Yes No         Fire Protection Class:  
  Protective Devices:  
    Deadbolt Locks  Smoke Alarms    Fire Extinguishers Alarm System    Monitored Alarm System    Home Sprinkler System

   
  CURRENT INSURANCE & HOME PURCHASE INFORMATION
  Previous Homeowners:   Prev Ins Co:  
  Policy#:   Policy Expiration Date :  #Years with Company :   
  How Buying:  By Owner? Yes No    Realtor: Ph#:
  Mortgage Co.  Ph# of Bank or Mortgage Company:  Address:
  Amount of House $:    Any Claims [3-5yrs]:
  Coverage Amounts:    Dwelling:   Other Structures:    Living exp:
  Personal Property  Liability:  Medical:
  DED:    Other:
  Reference Number :   Date:  
   
                                               When Done, Please     or      the Form. Thank You!