Network Insurance Center

Name:		Daytime Phone:
Address:		Cell Phone:
City:		Fax:
State:		E-mail:

Credits Available:
Dead Bolt Locks: Fire Extinguishers: Smoke Detectors: Non-Smokers: Burglar/Fire Alarm (send copy of installation/service certificate)

Replacement Cost Information:
Number of Stories: Square Footage: Construction:

Please answer YES or NO to each of the following questions:
Porch (open or enclosed):	Yes No	SquareFootage:
Deck/Balcony:	Yes No	Square Footage:
Auto Insurance:	Yes No
Extra Baths:	Yes No	#Full # Half

Central Air:	Yes No
Garage:	Yes No

Do you have any of the following?
Swimming Pool:	Yes No
Diving Board:	Yes No
HP:	Yes No		Value:
Slide:	Yes No
Hot Tub:	Yes No
Any Items to Schedule: Jewelry, Furs, Computers, etc.	Yes No
Do you have a mortgage on your home?	Yes No Purchase Price: Market Value:

Please explain any alterations to your home:
A Photo of the Dwelling is Mandatory