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Property Information
Contact Information
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Property Type
Select
Single Family Dwelling
Duplex
Multi Family Dwelling
Townhome
Mobile Home
Condominium
Construction
Select
Wood Frame
Metal Frame
Masonry
Log Home
Other
Service Panel
Select
Circuit Breaker
Fuse Box
Other
Unknown
Wiring
Select
Copper
Aluminum
Knob and Tube
Unknown
Garage Type
Select
No garage
Carport
Attached - 1 Car
Attached - 2 Cars
Attached - 3 Cars
Not Attached - 1 Car
Not Attached - 2 Cars
Not Attached - 3 Cars
Other
Bedrooms
Select
0
1
2
3
4
5
6
7
8
9
Stories
Select
1
1 1/2
2
3
4
Bi-level
Tri-level
Heating Type
Select
Gas Forced Air
Boiler
Oil
Propane
Electric
Stove
Other
Unknown
Year Built
Select
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
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1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
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1958
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1953
1952
1951
1950
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1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
Ok to Estimate
House Value
Select
50000
75000
100000
125000
150000
175000
200000
225000
250000
275000
300000
325000
350000
375000
400000
425000
450000
475000
500000
Ok to Estimate
Occupancy
Select
Primary Residence
Seasonal
Vacation
Tenant Occupied
Foundation
Select
Basement
Open (Cement Non-Solid)
Slab (Cement Solid)
Piers Pilings Stilts
Other
Security System
Select
No security alarm system
Sound alarm in home only
Signals monitoring company
Roof Type
Select
Asphalt Shingle (Common)
Composition Shingle
Wood Shingle
Tile Shingle (Spanish roof)
Metal Roof
Flat Roof
Other
Exterior Walls
Select
Mostly Brick
Mostly Wood Frame
Mostly Stone
Aluminum Siding
Vinyl Siding
Veneer
Cinder Block
Stucco
Other
Bathrooms
Select
0
1
2
3
4
5
6
7
8
9
Fireplaces
Select
0
1
2
3
4
5
6
7
8
9
Dog
Select
None
Doberman
German Shepherd
Pit Bull
Rottweiler
Other
Square Footage
Select
500
600
700
800
900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
2500
2600
2700
2800
2900
3000
3100
3200
3300
3400
3500
3600
3700
3800
3900
4000
4100
4200
4300
4400
4500
4600
4700
4800
4900
5000
Ok to Estimate
Coverage Type
Select
Full Package
Fire and Liability
Liability Only
Deductible
Select
$100
$250
$500
$1,000
$2,500
Coverage Amount
Select
$100,000
$300,000
$500,000
$1,000,000 (umbrella)
$3,000,000 (umbrella)
$5,000,000 (umbrella)
Credit History
Select
Poor
Average
Good
Excellent
Is this property a new purchase?
Yes
No
Is this property within city limits?
Yes
No
Is this property used for business or farming?
Yes
No
Any home insurance claims in the past 3 years?
Yes
No
Claim Type
Select
Weather
Vandalism
Fire
Water
Theft
Other
Claim Date
month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
day
1
2
3
4
5
6
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25
26
27
28
29
30
31
year
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
Do you currently have home insurance?
Yes
No
Company
Please Select
AIG
AIU Insurance
Allied
Allstate County Mutual
Allstate Indemnity
Allstate Insurance
American Alliance Insurance
American Automobile Insurance
American Casualty
American Deposit Insurance
American Direct Business Insurance
American Empire Insurance
American Family Insurance
American Family Mutual
American Financial
American Home Assurance
American Insurance
American International Ins
American International Pacific
American International South
American Manufacturers
American Mayflower Insurance
American Motorists Insurance
American National Insurance
American Premier Insurance
American Protection Insurance
American Service Insurance
American Skyline Insurance Company
American Spirit Insurance
American Standard Insurance - OH
American Standard Insurance - WI
Amica Insurance
Arbella
Associated Indemnity
Atlanta Casualty
Atlantic Indemnity
Auto Club Insurance Company
Blue Cross and Blue Shield
Cal Farm Insurance
California State Automobile Association
Chubb
Citizens
Clarendon American Insurance
Clarendon National Insurance
CNA
Colonial Insurance
Company Not Listed
Continental Casualty
Continental Divide Insurance
Continental Insurance
Cotton States Insurance
Country Insurance and Financial Services
Dairyland County Mutual Co of TX
Dairyland Insurance
Electric Insurance
Erie Insurance Company
Erie Insurance Exchange
Erie Insurance Group
Erie Insurance Property and Casualty
Farm Bureau/Farm Family/Rural
Farmers Insurance
Farmers Insurance Exchange
Farmers TX County Mutual
Fire and Casualty Insurance Co of CT
Firemans Fund
Geico Casualty
Geico General Insurance
Geico Indemnity
GMAC Insurance
Golden Rule Insurance
Government Employees Insurance
Grange
Guaranty National Insurance
Hanover Lloyds Insurance Company
Hartford Accident and Indemnity
Hartford Casualty Insurance
Hartford Fire Insurance
Hartford Insurance Co of Illinois
Hartford Insurance Co of the Southeast
Hartford Omni
Hartford Underwriters Insurance
Health Plus of America
IFA Auto Insurance
IGF Insurance
Infinity Insurance
Infinity National Insurance
Infinity Select Insurance
Integon
Kaiser Permanente
Kemper Lloyds Insurance
Landmark American Insurance
Leader National Insurance
Leader Preferred Insurance
Leader Specialty Insurance
Liberty Insurance Corp
Liberty Mutual Fire Insurance
Liberty Mutual Insurance
Liberty Northwest Insurance
Lumbermens Mutual
Mass Mutual
Mercury
Metropolitan Insurance Co.
Mid Century Insurance
Mid-Continent Casualty
Middlesex Insurance
Midwest National Life
MSI Insurance
Mutual of New York
Mutual of Omaha
National Ben Franklin Insurance
National Casualty
National Continental Insurance
National Fire Insurance Company of Hartford
National Health Insurance
National Indemnity
National Union Fire Insurance of LA
National Union Fire Insurance of PA
Nationwide General Insurance
Nationwide Mutual Fire Insurance
Nationwide Mutual Insurance
Nationwide Property and Casualty
New York Life Insurance
Northwestern Mutual Life
Northwestern Pacific Indemnity
Omni Indemnity
Omni Insurance
Orion Insurance
Pacific Indemnity
Pacific Insurance
Pafco General Insurance
Patriot General Insurance
Peak Property and Casualty Insurance
PEMCO Insurance
Progressive
Progressive Auto Pro
Prudential Insurance Co.
Reliance Insurance
Reliance National Indemnity
Reliance National Insurance
Republic Indemnity
Response Insurance
Safeco
Safeway Insurance
Safeway Insurance Co of AL
Safeway Insurance Co of GA
Safeway Insurance Co of LA
Security Insurance Co of Hartford
Security National Insurance Co of FL
Sentinel Insurance
Sentry Insurance a Mutual Company
Sentry Insurance Group
Shelter Insurance Co.
St. Paul
St. Paul Fire and Marine
St. Paul Insurance
Standard Fire Insurance Company
State and County Mutual Fire Insurance
State Farm County
State Farm Fire and Cas
State Farm General
State Farm Indemnity
State Farm Insurance Co.
State Farm Lloyds Tx
State Farm Mutual Auto
State National Insurance
Superior American Insurance
Superior Guaranty Insurance
Superior Insurance
The Ahbe Group
TICO Insurance
TIG Countrywide Insurance
Travelers Indemnity
Travelers Insurance Company
Tri-State Consumer Insurance
Twin City Fire Insurance
Unicare
United Pacific Insurance
United Security
United Services Automobile Association
Unitrin Direct
USAA Casualty Insurance
USAA General Indemnity
USF and G
Viking County Mutual Insurance
Viking Insurance Co of WI
Windsor Insurance
Woodlands Financial Group
Company Not Listed
AAA Insurance Co.
21st Century
Esurance
Years With Company
Select
0
1
2
3
4
5
6
7
8
9
10
Annual Premium Payment
Insurance Expiration Date
month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
day
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29
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31
year
2012
2013
2014
Continuously Insured
Select
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10+ Years
Home Accessories
Which residence accessories are part of this property?
Central Fire Alarm
Swimming Pool
Trampoline
Patio
Dead Bolts
Fire Extinguishers
First name
Last name
Gender
--
Female
Male
Birthdate
month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
day
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year
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
Telephone
Email
Zip code
Street address
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