TEST – FORM Name Name (Spouse) Date of Birth Date of Birth (Spouse) Phone Number Email Address or other contact Location Address (Please also list mailing address if different.) (If you've lived at this address less than 5 years, please list prior address also.) Construction Info: Year of original construction Style of original home Above ground square ft of original home Below ground construction of original home ---BasementSlabCrawl If basement, % finished: Additions (Year, style, size & below ground construction. Including % finished if basement.) Exterior construction Garage (Yes/No, Attached/Detached, # of Vehicles) Deck, porch, patio, etc (Yes/No, Type, Size) Detached Structures (If yes, what? Heated [If yes, by what]?) # of Baths (# of Full & # of 1/2) Central Air YesNo Fireplace (Yes/No, Gas/Wood/Wood Stove) Flooring (% of Each Type) Age & type of roof Age & type of heating Age & type of electric Circuit BreakersFuses Security or Sprinkler System (If yes, what?) Repairs Needed Current Insurance Info: Current coverages (Include company, due date, coverages, deductible & endorsements) Additional Info: Purchase date # of consecutive years you've carried a homeowner-type policy? (Including home, condo, mobile home & tenant) Valuable Contents (Type & Value) (ie Jewelry, Guns, antiques, artwork, etc) Have you filed a homeowner claim in the last 5 years on any property? (If yes, please list when and what) Smoker/Non-Smoker (All Residents) Bankruptcy in the last 5 years? (If yes, when?) Is there a pool, hot tub, bike/skate ramp or trampoline on your property? (If yes, what?) Do you have any pets or livestock? (If yes, what breed?) Business conducted in your home? (If yes, what?) How many acres does your home sit on? Do you own any other properties? Deductible options you would consider Do you have any toys? (ie boat, motorcycle, atv, snowmobile, golf cart, RV, etc) If you have a copy of your current "Declaration Page", please forward that to us as proof of prior coverage and to use for comparison purposes. Submission of information for a quote in no way binds coverage. Personal information will be used solely for underwriting purposes. Submission of information gives the Gary J Bach Agency permission to run all reports necessary to quote accurate insurance premiums.