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Contact Information
Client Name:
Street Address:
City:
State:	Zip:
Phone:
Best time to call:	AM   PM
Email:
Preferred contact:	Phone   Email
Comments:

Home Information
Property Type:	Home   Condo   Mobile Home   Apartment
Coverage:	Home Owners Insurance   Renters Insurance
Year Built:		Square Footage:
Number of stories:		Number of Bedrooms:
Purchase Date:		Home's Market Value:	(USD)
For Condos & Apartments only:		Number of Units in Bldg:
Type of Roof:	Concrete Tile   Asphalt   Other
Exterior Walls:	Stucco on Wood   Brick   Other
Construction:	Frame   Brick   Other
Flooring:	% Carpet   % Tile   % Wood   % Other
Upgrades in Kitchen:	Yes   No
Swimming Pool:	Yes   No
Number of Fireplaces:
Special Windows or Doors:
Monitored Alarm System:	Yes   No
Guest Medical Protection:	(USD)
Current Insurance Co:
Claims in Last 5 Years:	Yes   No
Policy Number:
Current Dwelling Coverage:	(USD)
Current Liability Coverage:	(USD)
Deductible:	(USD)
Marital Status:	Single   Married   Divorced   Widow(ed)
Face Value Amount of Current Life Insurance Policy for
Yourself:	(USD)   Spouse: (USD)
Require Flood Insurance:	Yes   No
Insurance companies use claim history and insurance financial scores to obtain accurate quoting information and as part of the underwriting and rating process.
May we have your permission to order these reports?:   Yes   No

Jim Gaudiosi - 4960 S Gilbert Rd, Suite 13 - Chandler, AZ 85249
Phone 480-854-6789   |   Fax 480-802-5694   |   Email JimGaudiosi@msn.com