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Select an Agent:	None Eric Gausepohl John T. Gausepohl Matt Gausepohl
Name:	*
Address:
City:
State:
ZIP:
Telephone:
Best Time to Call:
Fax:
E-Mail:	*
Estimated Effective/Closing Date:
Current Carrier:
Year Built:
Stories:	1 1 1/2 2 2 1/2 3
Foundation:	Basement Crawl Space Slab
Roof:	Asphalt Shingle Clay Tile Concrete Tile Other Wood Shake
If you selected other, please provide details.
Square Footage:
Exterior Wall Information
Frame:	Yes	No
Aluminum	Brick
Siding	Stucco
Vinyl
Garage Type:	Attached Built-In Detached
Garage Size:	1 Car 2 Car 3 Car 4 Car
Number of Bedrooms:
Number of Full Baths:
Number of 3/4 Baths:
Number of 1/2 Baths:
Laundry Room:
Water Heater:
Fireplaces:	Yes	No
Number of Hearths:
Number of Chimneys:
Gas Vent (No Chimney):	Yes	No
Heating Information
Electric	Forced Air
Gas	Hot Water
Radiant Floor	Wall Heater
Wood Stove
Cooling Information
Central Air:	Yes	No
Duct Type:	Same Separate
Whole House Fan:	Yes	No
Balcony/Deck:	Yes	No
Square Footage:
Porch/Breezeway:	Yes	No
Open Square Footage:
Enclosed Square Footage:
Screened Patio Information
Screened Patio:	Yes	No
Square Footage:
Foundation	Posts
Slab
Extra Buildings:
Built-Ins Information
Built-Ins:	Yes	No
Central Vacuum	Fire Sprinklers
Intercom/Stereo System	Jacuzzi
Sauna	Skylight
Solar Panels	Wet Bar
Flooring Information
Carpet	Concrete
Granite	Hardwood
Laminate	Slate
Stone	Tile
Vinyl
Alarm Information
Burglary Alarm	Central
Fire Alarm	Local
Police/Fire Dept.	Smoke Detector
Pool:	Yes	No
If yes, is it fenced?	Yes	No
Diving Board:	Yes	No
Trampoline:	Yes	No
Gated Community:	Yes	No
Pets:
Sign Dog Exclusion:	Yes	No
Losses:	Yes	No
If yes, please provide details.
Updates Information
Electrical:	Yes	No
Circuit Breakers	Fuses
Heating:	Yes	No
Plumbing:	Yes	No
Copper	Galvanized
PVC
Roof:	Yes	No
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