Date(s) of Birth: /

Address:

City: State: Zip:

Phone:

Social Security Number(s) Both Applicants: /

Occupation(s): /

Number of Families: Year Built:

Construction Type: Frame Masonry

Type of Home:
                       (Colonial, Cape, Ranch, Raised Ranch etc)

Miles from Fire Department: Feet from Hydrant:

List protections systems:
                                      (smoke detectors, fire ext, dead bolts, alarm systems)

Is any resident a smoker?: Yes No

Present Limit of Coverage:	$	$
	Dwelling Limit	Contents Limit

Deductible: $ Policy billed to: Mortgagee Insured

Present Liability Limits:	$	$
	Personal Liability	Medical Payments

List any additional coverage: $
                                       (Scheduled jewelry values, values of collectibles etc.)

Mortgagee/Loan Number:
As shown on the policy

List Previous Claims:

Current Insurance Company: Expiration Date:

Present Policy Number: Present Premium: $

Total Square Footage: First Floor Sq. Ft.:

Square Footage of Basement: Number of Stories:

Construction Quality:
                                      (standard, custom, luxury)

Number of Bedrooms: Number of Bathrooms:

Check those that apply:

Den, Study, Office Dining Room Double Sized Rooms Family Room Kitchen Living Room 2 Car Attached Garage 1 Car Attached Garage Finished Attic # Fireplaces # Chimneys

Central Air Central Air Separate Ducts Finished Basement Wood/Coal Stove Central Heat Within 1000 feet of seashore Above Ground Pool In-Ground Pool Fencing Detached Structures/Garage Trampoline

Deck Dimensions:
Open Porch Dimensions:
Enclosed Porch Dimensions:

Flooring %: Hardwood Carpet Tile Marble Vinyl

Number of Dogs/Pets and Type/Breed:

Roof Type:    Type of Heat (Oil/Gas/Elec):

Electrical Amp Service: # of Amps   Fuse Circuit Breakers

Oil Tank Storage Location:

Updates Made:

	Year		Year
Roof:		Electrical:
Heating:		Furnace Age:
Plumbing:

Vinyl Siding Wood Shake Aluminum Siding Clapboard Other

If other, please describe:

Has applicant had a foreclosure, repossession or bankruptcy during the past 5 years? Yes No

A PHOTOGRAPH OF THE FRONT AND BACK OF YOUR HOME IS REQUIRED

Please send photograph to:
New England Insurance Services, Inc.
P.O. Box 63, Weatogue, CT 06089-0063
Phone (860) 844-8288 Fax (860) 844-8274