Step 1 of 4 25% Prospect Name PhoneEmail Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Line of Business Auto Renters Home Lead SourceFirst ChoiceSecond ChoiceThird ChoiceAgentAmanda FullerJames ItellMadison Wilhide VehiclesYear Make ModelVIN Add RemoveDriversNameDate of BirthLicense Number Add RemoveRideShare Activity Yes No Kids away at school Yes No Vehicle Ownership Yes No Are all vehicles owned by the named insuredNotesCoverage amounts, deductibles, good student discount Have renters currently? Yes No Is your name on the lease? Yes No Any dogs? Yes No BreedBreedBite History Add RemoveRequested replacement cost contents Home in your name Yes No Purchase Year Year Built Number of bathroomsNumber or car garageDeck/Porch Deck Screened in porch Patio Covered patio Deck/porch SizeDo you have? Trampoline Pool Dogs Trampoline Netted Grounded Pool In ground? Above ground? Fenced? Diving Board? Water Slide DogsBreedBite history Add RemoveHeating System Gas Electric Oil It has been replaced Year Replaced Fireplace/Woodstove Gas Fireplace Wood Fireplace Woodstove Roof type Shingle Metal Mix It has been replaced Year Replaced Security Deadbolt locks Fire extinguisher Smoke/CO detector Central Security System Home security system (ring) Water detection device Potential scheduled items Jewelry Fine Arts Guns Collectibles Do you have any? Airbnb/Rental Yes I rent out on Airbnb No How often? Business activity at home Yes No How often? Percent of basement finished?Current DeductibleAny renovations or other notes
