Current Homeowners Insurance Information
Company Name (not agency):
Policy Expiration Date:	Premium Amount: $
Amount Insured For:	$     Policy Type: Primary Secondary
Deductible Amount:	-- Select One -- $250 $500 $1,000
Term:	6 Months   1 Year   Other:
Please FAX or EMAIL a copy of your current policy to:
Fax:  (603)625-6140 Email:  service@nerisk.com

Home Information
How Long At Present Address:	Year Home Was Built:
Sq. Footage (excluding garage and basement):	sq. ft.         # of Claims In Last 3 Years:

Structure Information
Type	Construction	Roof	Foundation	Garage
1 Story 1 1/2 Story 2 Story Split Level Bi-Level Other	Frame Stucco Veneer Masonry Other	Asphalt Shingle Wood Shingle Tile or Slate Other	Basement Crawl Space Slab Other	1 Car 2 Car 3 Car 4 Car None
		Age of roof: yrs.		Attached Detached Basement Built-in Car Port None

Features
Bathrooms	Basement	Deck/Porch/Patio	Fireplaces
# of Full: # of Half:	None Finished Unfinished Sq. Ft.:	Deck Sq. Ft.:     Porch Sq. Ft.:     Screened Patio Sq. Ft.:	# of Chimneys:     # of Hearths:

Additional Features
Heating System	Central Air	Central Vac	Security Alarm	Fire Alarm	Smoke Detector
None Electric Gas Oil Propane Solar Other	Yes	Yes	None Monitored Not Monitored	None Monitored Not Monitored	Yes

Home Updates
Please give the year(s) the following were last upgraded:
Heating System	Roof	Plumbing	Electrical

More Information
Please answer "Yes" or "No" if your home has:
Trampoline	Circuit Breakers	Dog(s)	Pool	Woodstove	Special Jewelry Coverage
Y   N	Y   N	Y   N	Y   N	Y   N	Y   N

Additional Comments

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