* First Name
* Last Name
* Email
* D.O.B.
Phone
* Address 1
Address 2
* City
* State	CA
* Zip
* Occupancy	Owner Occupied Tenant Occupied Vacant
Type of Construction	Wood Frame Masonry/Brick
* Year Built
* Square Footage
* Number of Stories	1 Story 2 Story 3 Story
* Type of Roof	Composition Tile Wood Shake Wood Shingle
Central Alarm	No Yes
Number of Fireplaces	none 1 2 3
* Type of Garage	1 Car Attached 2 Car Attached 3 Car Attached 1 Car Detached 2 Car Detached 3 Car Detached 1 Car Carport 2 Car Carport 3 Car Carpott No Garage/Carport
Updates to Home
Purchase Date
Purchase Price
* Feet to Fire Hydrant	Less than 1000 More than 1000
* Miles to Fire Station	Less than 5 More than 5
Current Insurance Company
Current Dwelling Coverage
Deductible	$500 $1000 $2000 Other
Personal Liability Limit	$100,000 $200,000 $300,000 $500,000
Additional Information
	* = Required Field