Home Intake Form Agent First Last Agent PhoneClient Name First Last Client DOB MM slash DD slash YYYY Client PhoneClient Email Client Spouse Name First Last Spouse DOB MM slash DD slash YYYY Insured Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Current Carrier Effective/Expiration Date MM slash DD slash YYYY Property InformationProperty TypeSingle FamilyMulti FamilyCondoTownhomeVacant/RehabRentalSecondary/VacationYear Built Majority Exterior MaterialVinyl SidingWood SidingBrickStuccoOtherHome Style1 Story1.5 Story2 StorySplit LevelSquare Footage (excluding basements) Number of BathroomsRoof TypeAsphalt ShingleArchitectural ShingleMetalFlat or RubberOtherHeating System TypeNatural GasWood FuelOil FuelOtherBasement TypeNo BasementUnfinished BasementPartially Finished (Under 50%)Partially Finished (50 - 95%)Fully Finished (95%+)Garage TypeNo GarageDetached Garage Under 2 carsAttached Garage Under 2 carsDetached Garage 2+ carsAttached Garage 2+ carsSystem UpdatesRoof AgeReplaced within 5 YearsReplaced within 10 YearsReplaced Between 10 & 15 YearsOlder than 15 Years OldHeating System AgeReplaced within 5 YearsReplaced within 10 YearsReplaced Between 10 & 15 YearsOlder Than 15 YearsElectrical System AgeReplaced within 5 YearsReplaced within 10 YearsReplaced Between 10 & 15 YearsOlder Than 15 YearsPlumbing System AgeReplaced within 5 YearsReplaced within 10 YearsReplaced Between 10 & 15 YearsOlder Than 15 YearsUnderwritingAny homeowners claims in last 5 years?NoYesDo you have any of the following? Dog(s) Swimming Pool Trampoline Deck What is the breed of your dog? Pool TypeIn-ground w/fencingIn-ground w/o fencingAbove-ground w/fencingAbove-ground w/o fencingAdditional Comments or Notes
