crawford insurance agency inc

Complete Insurance Service Since 1943

Protection Through Strength

Homeowner Insurance Information Form

Personal Information Salutation: Mr. Mrs. Ms. Miss
First Name: Last Name: MI:
Address line 1:
Address line 2:
City: State: Zip Code:
Home Phone: Work Phone:
Best time to call: at home work
Email Address Social Security Number:

Insurance Coverage Information Current Insurance Company:
Expiration Date:

Type of Insurance	Limits	Type of Insurance	Limits
Dwelling		Loss of Use
Other Structures		Personal Liability
Medical Payments		Personal Property

Have you filed a claim within the last tree years? Yes No
Have you ever been denied a claim? Yes No

Home Information Is this property a new property? Yes No
If yes, when is the closing date? (mm/dd/yyyy)

Is the property located above? Yes No
If no, please provide property address:
Address line 1:
Address line 2:
City: State: Zip Code:

What year was the property built? (yyyy)	Approximate Square Feet:
House Type:	Number of Stories:
Number of Bedrooms	Number of Bathrooms
Type of Garage	Number of Cars:
Primary Heat Source:	Secondary Heat Source:

Please explain below, if there has there been any major renovations to the property.

Is the property mortared? Yes No
If yes please provide the name of the the mortgage company and their address below:

Home Safety

Is the property within 5 miles of a fire department?	Yes No
Is there a fire hydrant within 1000 feet?	Yes No
Do you have any livestock or pets?	Yes No
Is there a swimming pool on the property?	Yes No
Do you have a trampoline?	Yes No
Do you have any recreational vehicles (ATV, 4-wheeler, etc)?	Yes No
Do you conduct business in your home?	Yes No
Can you neighbors see your house?	Yes No

Other Please use the field below for any additional information: