Wufoo

Subject Property address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Is the Subject Property a New Purchase? Yes / No
Yes No
If yes, date of closing MM / DD / YYYY
Customer’s Name: First Last
Customer’s Current Mailing Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Customer’s Phone # ### - ### - ####
Cell # ### - ### - ####
Marital Status for Insured
Single Married Other
Date of Birth for named insured MM / DD / YYYY
Underwriting
Select occupancy type: Select one:
Primary residence (owner occupied) Single Detached Family Home Duplex Rental property Condominium/Townhome Triplex Secondary/vacation home Mobile home Other
Select construction type: Select foundation type:
Frame Slab Brick Concrete Perimeter Masonry veneer Combination of above Other
If other selected, type of roof
Year Built:
Garage
Attached Detached
Number of stalls
Square footage:
Number of stories
Number of fireplaces
Pool
Yes No
Fire hydrant within 1,000 ft:
Yes No
If yes, is the pool/yard fenced?
Paid fire dept within 5 miles:
Yes No
Diving board or pool slide?
Brush/Forest within 400 feet:
Yes No
Trampoline:
Yes No
Type of roof
Plumbing Type
Woodstove
Yes No
Age of roof:
Pets
Yes No
If yes, what breed & how many?
Business/Childcare conducted out of home:
Yes No
If yes, provide details:
Closing Information:
Closing/Escrow/Loan officer:
Escrow/Reference/Loan
Phone Number ### - ### - ####
Fax Number ### - ### - ####
Do Not Fill This Out