Name(s): /

Address:

City: State: Zip:

Phone:

Email:

Occupation(s): /

Number of Families: Year Built:

Construction Type: Frame Masonry

Type of Home (Colonial, Cape, Ranch, Raised Ranch etc):

Miles from Fire Department: Feet from Hydrant:

List protections systems (smoke detectors, fire ext, dead bolts, alarm systems):

Is any resident a smoker?: Yes No

Present Limit of Coverage: Dwelling: $ Contents: $

Deductible: $ Policy billed to: Mortgagee Insured

Present Liability Limits: Personal Liability: $ Medical Payments: $

List any additional coverage (Scheduled jewelry values, values of collectibles etc.):
$

Mortgagee/Loan Number as shown on the policy:

List Previous Claims:

Current Insurance Company: Expiration Date:

Present Policy Number: Present Premium: $

Total Square Footage: First Floor Sq. Ft.:

Square Footage of Basement: Number of Stories:

Construction Quality (standard, custom, luxury):

Number of Bedrooms: Number of Bathrooms:

Check those that apply:

Deck Dimensions:

Open Porch Dimensions:

Enclosed Porch Dimensions:

Flooring:    Hardwood %    Carpet %    Tile %    Marble %    Vinyl %

Number of Dogs/Pets and Type/Breed:

Roof Type: Type of Heat (Oil/Gas/Elec):

Electrical Amp Service: # of Amps   Fuse Circuit Breakers

Oil Tank Storage Location:

Updates Made:

Type of Siding: Vinyl Siding Wood Shake Aluminum Siding Clapboard Other

If other, please describe:

Has applicant had a foreclosure, repossession or bankruptcy during the past 5 years? Yes No

A PHOTOGRAPH OF THE FRONT AND BACK OF YOUR HOME IS REQUIRED

Please send photograph to:

New England Insurance Services, Inc.
PO Box 63, Weatogue, CT 06089-0063
Phone: (860) 844-8288 Fax: (860) 844-8274