| Tell us about yourself |
| First Name: |
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| Last Name: |
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| Social Security #: |
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| Contact Phone: |
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| Fax: |
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| E-Mail: |
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| Address: |
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| City: |
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| State: |
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| Zip: |
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| Tell us about your house! |
| Location Information |
| Distance To Fire Hydrant: |
(in feet) |
| Distance To Nearest Responding Fire Department: |
(in miles) |
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| Residence Information |
| Type of Residence: |
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| Do You Reside In This Property: |
Yes No |
| Year built: |
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| Smoke Alarms: |
Yes No |
| Fire Extinguisher: |
Yes No |
| Central Station Alarm: |
Yes No |
| Dead Bolts: |
Yes No |
| Inside City Limits: |
Yes No |
| Have Pets: |
Yes No |
| Have Trampoline: |
Yes No |
| Have Pool: |
Yes No |
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| Total living area:Exclude balconies, basements, breezeways, decks, porches and garages. |
(app. square feet) |
| Total stories |
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| Primary exterior wall type |
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| Foundation type |
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| What percentage of living space is on the ground floor? |
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| Heating and cooling system |
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| Fireplaces |
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| Garage type |
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| How many cars does the garage hold? |
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| Number of Full bathrooms |
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| Number of Half bathrooms |
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| Number of Screened porches |
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| Tell us about your choice of coverage |
| Liablity Limits: |
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| Current Insured Value of Home: |
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| Deductible: |
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| Comments or Questions |
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Please make sure all the information is provided as accurate as possible.
By submitting this proposal form, the applicant permits Archer's Insurance Solutions to run appropriate credit reports as required by the underwriting companies.
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