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General Info:
*Prospect First Name			*Last Name
*Address of Property			*City
State		- California	*Zip
*Primary Contact Number			*Email
*Gender		Male Female	*Date of Birth
*Marital Status		--Select One-- Married Single Divorced Widowed	*Referring Agency or Individual
Spouse Name (If Married)			*Usage Type		--Select One-- Primary (Owner Occupied) Secondary Rental (Tenant Occupied) Seasonal Residence Vacant (Unoccupied)
Spouse Date of Birth
Property Info:
Square Footage			Construction Type		Frame Masonry Superior Masonry Veneer
Year Built			Roof Type		Asphalt Shingle Tile Slate Wood Shake Metal Other
Dwelling Type		--Select One-- Single Family Apartment Duplex Condominium Townhome Mobile Home Manufactured	Garage Type		--Select One-- Attached 1 Attached 2 Attached 3 Detached 1 Detached 2 Detached 3 Carport
Stories		--Select One-- One Two Three	Fireplace		--Select One-- None One Two Three Four
Purchase Date			Primary Heating System		--Select One-- Electric Gas Propane Wood Burning Stove
Aditional Info:
Distance from fire hydrant?		100 feet 200 feet 300 feet 400 feet 500 feet 1000+ feet	Updates:		Select Update / Enter Year
Distance from fire station		1 mile 2 miles 3 miles 4 miles 5 miles 10+ miles	Roof		--Select One-- Serviced Replaced Unknown
New Purchase		--Select One-- Yes No	Plumbing		--Select One-- Serviced Replaced Unknown
Impound Account/Mortgage Bill		--Select One-- Yes No	Heating		--Select One-- Serviced Replaced Unknown
			Electrical		--Select One-- Serviced Replaced Unknown
Requested Coverage:			Policy Information:
Liability coverage		$100,000 $300,000 $500,000	Have you filed a previous homeowners claim?		Yes No
Medical payments		$1,000 $5,000 $10,000 $25,000	Date of last claim
Policy deductible		$500 $1,000 $2,500 $5,000	Current policy with
			Current policy expires
Discount Info:
Fire Sprinklers		--Select One-- Full Partial None	Fire Alarm		--Select One-- Local (Not Connected) Station Connected Central Connected None
Gated Community/Security Guard		--Select One-- Yes No	Theft Alarm		--Select One-- Local (Not Connected) Station Connected Central Connected None
Check all that apply:		Dead Bolts	Smoke Detectors		Fire Extinguisher
		Swimming Pool	Trampoline		Covered Deck/Patio
Do you have any of the following Breeds of Dog: Yes No
Chow, Doberman, German Sheperd, Pit bull, Rottweiler, Akita, Wolf Hybrid, or any mix of these?
Deselect this box if you are real person.

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