Homeowner/Property Insurance Fact Sheet

Personal Information Full Name
Date of Birth
Social Security Number - -
Marital Status Married Single Divorced Widowed

Spouse Information Spouse Full Name
Spouse Date of Birth
Spouse Social Security Number --

Mailing Address Information Mailing Address (Line 1)
Mailing Address (Line 2)
City
State
Zip

Property Address Information Same as Mailing

Physical Address (Line 1)
Physical Address (Line 2)
City
State
Zip

Contact & Employment Info Email Address
Telephone Number
Cell Number
Place of Employment
Occupation
Years at Job

Property Information

Please give us the following information on your home:

Year Purchased
Year Built
Square Footage
Type of Heat / Air
Age of Roof (Yrs.)
Property Type/Construction Frame
Masonry / Brick
Manufactured Home
Mobile Home - Length (in ft.) and Width (in ft.)
Name of responding fire dept.
Miles from fire dept.
Feet from fire hydrant
Do you have an alarm system? Yes No
If yes, what type? Fire Theft Both
Reports to: Central Station Local Only
Occupied by: Tenant Owner

Insurance Information Any claims withing the last 5 years? Yes No
If yes, please give details (date of loss, type of loss and amount paid)
Current Carrier (if any)
Policy Number
Current Coverages
Current Deductible

Other Personal Information Have you filed bankruptcy in the last 7 years? Yes No

If So, When?
Has your bankruptcy been discharged? Yes No

Have you had a forclosure in the last 7 years? Yes No

Have you ever been convicted of any type of arson? Yes No

Legal Statement

In submitting this quote for insurance it is understood that as part of insurance company underwriting procedures an investigative consumer report may be prepared whereby information is obtained through both credit and clue reports. The information retrieved in these reports will be handled with confidentiality required by Federal guidelines.

I have read the above form and I do hereby give Fiser Insurance Agency and/or its affiliates permission to run reports that may be necessary in receiving a fair and accurate quote.

Signed