# Bedrooms:		# Bathrooms:
# Fireplaces:		# Chimneys:
Special features (i.e., deck, air conditioning, alarm systems, pool, etc.)
Coverages:
Dwelling Cov. $		Contents $
Liability Cov. $		Deductible $ ($250, $500, $1,000, etc.)
Disclaimer for Fair Credit Reporting Act : With your date of birth I will order an insurance score by law I must inform you- FCRA Compliance Notice required by the fair credit reporting act (FCRA) Federal Law (15 USC Sec. 1681D) requires all insurance companies to notify their applicants that an investigation may be made as to character, general reputation, personal characteristics and mode of living, whichever are applicable. As part of this underwriting process, insurance companies have a permissible purpose for procuring consumer reports. As part of the underwriting process, I must ask you a series of questions, some of which I will confirm through non-credit related consumer reports. I will also be accessing your credit information through a consumer reporting agency to generate a risk assessment indicator, which will be used to develop your quote. Do you agree to allow us to pull an Insurance Score using your current address and date of birth? YES    NO
Comments/Remarks (describe any scheduled jewelry, in-home business, oil tank location, or other special coverages/remarks here):
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