Mailing Address:    City:    Postal Code:

Location of Property to be insured :

Have you had any insurance claims in the

past 5 years ?                                     No Yes

What year was this home built ? :

Is this home within 1000 fee of a fire hydrant and 5 Miles of a responding fire hall            Yes No

Please indicate the type of central heating

Electric Baseboard Natural Gas Furnace Hot Water Oil Furnace Electric Furnace Heat Pump

Please select back up heating type:

Free Standing Woodstove Pellet Stove Gas Fireplace Fireplace Insert Propane Fireplace None

Amount of Monthly Rental Income:

 Have you hired a Property Manager to care for this home ?

Yes No

Please indicate the type of rental contract presently in place:

Month to Month 6 Month Lease One Year Lease Two Year Lease