Risk Information

Property Address:   City:  Zip:

Year Built:     Square Feet:  

# Levels: 1 2345   #Baths 1 2345   #Fireplace: 1 2345

Exterior: Stucco Comp SidingWood SidingBrickOther   Year Painted:  

Roof Type: TarGravel CompShingleModBidermunTileOther    Roof Age: 

Any Upgrades: Yes No

Occupied: Yes No     # Units: 0 1234     Market Value:      Loan Value:

Prior Losses/Claims: Yes No               List Claims:    

Coverage Information

Dwelling Amount $100,000 $150,000$200,000$250,000$300,000$350,000$400,000$450,000$500,000

Liability Limit $500,000 $100,000$300,000$1,000,000

     Deductible $500 $250$1,000

Extended Replacement   Code Upgrade 

Contact Info

First Name:   Last Name: 

Day Telephone:   ### ### ####     Fax:  ### ### ####

Email: name@jsins.com

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