Date of birth
Gender
Male
Female
Maritial Status
Married
Single
Divorced
Seperated
Widowed
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Address
City
State
ZIP
Is the mailing address the same as your street address ?
Yes
No
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Mailing - Address
Mailing - City
Mailing - State
Mailing - ZIP
First Name
Last Name
Email
*
Phone
*
State
DE
MD
NJ
PA
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Year built
Square footage
Number of stories
1
1.5
2
2.5
3
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Construction type
Brick, Stone or Masonry
Brick, Stone or Masonry Veneer
Fire Resistive
Frame
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Exterior Walls
Adobe
Brick, solid
Concrete, poured-in-place, 4 to 6
Shakes, wood
Siding, vinyl
Stucco on frame
Stone on frame
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Roof Material
Architectural Shingle
Asphalt Rolled
Composite Shingle
Foam
Metal
Rubber
Slate
Tar and Gravel
Tile, Clay
Tile, Spanish
Wood Shingle
All Other
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Select the foundation types that apply
Slab
Crawl space
Basement
Basement walkout
Suspended over hillside
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Number of half baths
0
1
2
3
4
5
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Description of half baths
Basic
Builder's Gate
Semi-Custom
Custom
Designer
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Number of full baths
0
1
2
3
4
5
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Description of full baths
Basic
Builder's Gate
Semi-Custom
Custom
Designer
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Number of kitchens
1
2
3
4
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Description of kitchens
Basic
Builder's Gate
Semi-Custom
Custom
Designer
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Type of garage
Attached Garage
Basement Garage
Carport
Detached Garage
Not Applicable
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Number of cars parked in the garage
1
2
3
4
5
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Is there a mortgage on this house?
Yes
No
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Estimated month and year of home purchase?
Year roof was last replaced?
How many years have you been continuously insured with your current home insurance carrier?
0
1
2
3
4
5 or more
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