Martinson, Inc.

Property Insurance

First Name

Last Name

Phone Number

Date of Birth

Drivers License Number

Street Address, City, Zip

Single/Married/Widowed

Name of Spouse

Spouse's Date of Birth

Spouse's Driver Licenser Number

Year Built

Sq Footage

Brick or Frame? If frame, which kind?

Style of home (ranch, two story)?

# of Bedroom and Baths

Central Air? Y/N

Fireplace? Y/N

Finished basement? Y/N, If yes, please provide the % of it to the basement

Deck? Y/N

Garage? Y/N, if yes, how many cars and detache or attached?

Age of Roof

Age of Furnance

Circuit Breakers & Amps?

Type of Plumping (galvanized, copper, pvc, pex)

Dogs? If so, which breed(s)?

Amount paid for home

Including children, how many people are living in the home

Prior Insurance? If so, with you and how long?

Any claims in the last 3 years?

Thanks for submitting!