Dwelling Information Survey (Complete only at agent direction)

Personal Information
First Name Required Input Required
Last Name Required Input Required
Date of Birth Required Input Required	Open the calendar popup. << < February 2012 > >>   S M T W T F S 5 29 30 31 1 2 3 4 6 5 6 7 8 9 10 11 7 12 13 14 15 16 17 18 8 19 20 21 22 23 24 25 9 26 27 28 29 1 2 3 10 4 5 6 7 8 9 10
Spouse First Name Optional
Spouse Last Name Optional
Date of Birth Required Input Required	Open the calendar popup. << < February 2012 > >>   S M T W T F S 5 29 30 31 1 2 3 4 6 5 6 7 8 9 10 11 7 12 13 14 15 16 17 18 8 19 20 21 22 23 24 25 9 26 27 28 29 1 2 3 10 4 5 6 7 8 9 10
E-Mail Address Required You must provide an e-mail address. A valid e-mail address is required.
Dwelling Information
Street Required Input Required
City Required Input Required
State Required Input Required	select FL IN OH
ZIP / Postal Code Required Input Required Please enter a valid Postal code.
Year Built Required Year Built must be answered
Construction Type Optional	select Frame Brick Masonry Aluminum Siding Other
Square Footage of Location Optional
Number of Stories NOT Including Basement Required 'Number of Stories NOT Including Basement' must be answered
Dwelling Substructure (Choose One) Optional	Basement Crawlspace Piers Slab
Basement Finished? Required 'Basement Finished' must be answered	Yes No
If "Yes" to finished basement, what percent is finished? Optional
Roof Type Optional	select Composition (fiberglass, asphalt, etc.) Asbestos shakes Copper Cedar Shakes Steel/Porcelain Shingles Plastic Recycled Roofing Products Roll Roofing Single Ply Membrane Systems Tar and Gravel Cedar Shingles Metal Concrete Tile Poured Rock Slate Tile Aluminum Shingles Wood Shake / Shingles Clay Tile Other
Age of Roof (Enter year roof replaced as yyyy) Required 'Age of Roof' must be answered
Heating Type Required 'Heating Type' must be answered	select Coal Electric (including heat pump) Geothermal Kerosene Natural Gas Oil Portabel/Non-thermostatically controlled Propane Solar Space Heater Wood
Age of Heating (Enter year heating was replaced as yyyy) Required 'Age of Heating' must be answered
Does the Dwelling have Central Air Conditioning? Required 'Central Air Conditioning' must be answered	Yes No
Wiring Type Required 'Wiring Type' is a required field	select Circuit Breakers (200amp or more) Circuit Breakers (Less than 200amp) Fuses Combination Circuit Breaker/Fuses
Age of Wiring (Enter year wiring was replaced as yyyy) Required 'Age of Wiring' must be answered
Number of Full Bathrooms Required 'Number of Full Bathrooms' must be answered
Number of Half Bathrooms Required 'Number of Half Bathrooms' must be answered
Total Square Footage of Porches Optional
Total Square Footage of Decks Optional
Indicate Number of Fireplaces Required 'Fireplaces' must be answered
Indicate Number of Woodstoves Required 'Woodstoves' must be answered
Is there an attached garage? Required 'Attached Garage' must be answered	Yes No
If "Yes" to is there an attached garage, how many cars does it hold? Optional	select Carport 1 2 2½ 3 3½ 4 4½ 5 5½ 6
Is there a swimming pool on the premises? Required 'Swimming Pool' must be answered	Yes No
If "Yes" to is there a swimming pool on the premises, please specify all that apply Optional	Above Ground In Ground Completely Fenced Partially Fenced Diving Board Slide
Is there a trampoline on the premises? Required 'Trampoline' must be answered	Yes No
If "Yes" to is there a trampoline on the premises, please specify all that apply Optional	Trampoline is Fenced Trampoline has Safety Netting
If animals are present on premises, please indicate types and breeds Optional
Is any business conducted from the premises? Required 'Business on Premises' must be answered	Yes No
If "Yes" to is any business conducted from the premises, please describe business Optional
Distance to Fire Hydrant Required 'Distance to Fire Hydrant' must be answered
Name of Responding Fire Department Required 'Fire Department' must be answered
Does the dwelling have any of the following security measures? (Mark all that apply) Optional	Central Burglar Alarm (ADT, Brinks, FrontPoint) Central Fire Alarm (ADT, Brinks, FrontPoint, etc.) Deadbolt Locks Fire Extinguisher Smoke Alarms
Mortgage / Lender Information
Lender Name Optional
Lender Contact Person Optional
Lender Phone Number Optional
Will home insurance be paid by the lender? Optional	Yes No
Lender Address Optional
Lender Loan Number (if available) Optional
Date closing is scheduled to close Optional	Open the calendar popup. << < February 2012 > >>   S M T W T F S 5 29 30 31 1 2 3 4 6 5 6 7 8 9 10 11 7 12 13 14 15 16 17 18 8 19 20 21 22 23 24 25 9 26 27 28 29 1 2 3 10 4 5 6 7 8 9 10
Builder's Risk Information (Complete if dwelling will be in the course of construction)
Are you responsible for the theft of building materials? Optional	Yes No
Does your contractor have any special conditions in your contract? Optional	Yes No
If "Yes" to contractor special conditions, please specify Optional
Enter Validation Code Required

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