Homeowner, Renter, or Mobile Home Application With this information we can get started on your quote more quickly. There are four parts: 1. Contact Information2. Resident Information3. Dwelling Information4. Background Information Step 1 of 4 25% 1. Contact Information:Name* First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Work PhoneCell PhoneEmail* Preferred Contact Method Home Phone Work Phone Cell Phone E-mail 2. Resident InformationInsuredName First Last DOB SS# Employer and Occupation Years Employed Marital Status Married SIngle Separated Divorced Widowed Education Level High School Associate's Degree Bachelor's Degree SpouseName First Last DOB SS# Employer and Occupation Years Employed Marital Status Married SIngle Separated Divorced Widowed Education Level High School Associate's Degree Bachelor's Degree Children in Household:NameDOBSS# (if any) We need this information for each child. Click the + button to add another child. 3. Home InformationType of Insurance Homeowners Tenant Dwelling Renters Mobile Home Year Built - if knownNumber of StoriesGround Floor Sq. Footage - if known2nd Floor Sq. FootageNo. of RoomsNo. of BathsNo. of FireplacesCentral Air Yes No Central Heat Yes No Space Heater Yes No Construction Type - if known Stucco, Wood, Brick, Brick Veneer, Etc.Roof Type Metal, Compensation, Etc.Age of Roof (in years)YearMake Model Length (in feet)Width (in feet)Serial Number Type of Residence Primary Residence Seasonal Residence Tenant Vacant Fireplace? Yes No Factory Installed Fireplace? Yes No Exterior Wood / Masonite Vinyl Siding Metal 4. General InformationLocation to be Insured AcresIn Mobile Home Park? Yes No Inside City Limits? Yes No Years Lived ThereGarage Size (no. of cars) Attached Detached Carport None Attached Detached Porch Size (sq. ft.) Attached Detached Other Buildings:TypeSq. Footage Greenhouse, Shed, Workshop, etc. Click the "+" button to add another building.Updates in House Plumbing Heating Wiring Year Plumbing UpdatedYear Heating UpdatedYear Wiring UpdatedAnimals:Type (Dog, Horse, etc)Breed (of Dog) Click the "+" button to add another animal.Pool? Yes No Trampoline? Yes No Amount of Insurance NeededAmount for BuildingAmount for ContentsAny Special Insured ItemsAny Claims in the Last 5 years? Yes No Please Describe the ClaimAmount PaidMortgagee Prior InsuranceInsurer Expiration Date MM slash DD slash YYYY Years with InsurerTo provide you a firm estimate, our Insurance carriers use information from various reports, such as House Hold Summary Report, C.L.U.E. (claims history) and credit, from consumer reporting agencies. These reports periodically could be ordered to renew or update your insurance. You can obtain a copy of your reports for verification or correction within 60 days through the consumer reporting agencies. Talley-Reed Insurance Agency has strong procedures in place to protect your personal information.