Name:
Address:
City:   State: Utah  Zip:
Contact Phone:
Contact Email:
Date of Birth: (MM/DD/YYYY)

Insurance policy type: SELECT Homeowners (Primary) Landlords Condo/Townhouse (Contents Only)

Year Built:
Square Footage: (excluding the basement)
Basement Square Footage:
Basement Square Footage Finished:
Home Style: SELECT Rambler/Ranch Two-Story Split-Level Bi-Level/Raised Ranch Other Unsure
Construction Type: SELECT Aluminum/Vinyl Siding Solid Brick Stucco Stucco/Brick or Stone Wood Siding Other
Brick/Stone Veneer %: %0 %10 %15 %20 %25 %30 %35 %40 %45 %50
Roof Type: SELECT Asphalt Shingles Tile Copper Metal Wood Shingles Other
Garage Type: SELECT None Carport Detached 1 Car Attached 2 Car Attached 3 Car Attached 4 Car Attached 1 Car Built-in 2 Car Built-in 3 Car Built-in
Full Bathrooms: 0 1 2 3 4 5 6
Half Bathrooms: 0 1 2 3
Fireplaces: 0 1 2 3 4
Home Security: SELECT Deadbolts Only Fire Alarm Only Burgler/Fire Alarm
Deck:YesNo
Dwelling Coverage: $ (example 250,000)
Personal Liability Coverage: $100,000 $300,000 $500,000 $1,000,000
Deductible: $500 $750 $1000 $2500
Current Insurance Company: SELECT Allstate Insurance American Family Bear River Mutual Farm Bereau Liberty Mutual MetLife Nationwide Group State Farm Group USAA Group OTHER NONE

Have you filed any claims in the past three years? Yes No

If Yes, please explain your claims for the past 3 years.

Comments: