CONTACT INFO First Name:* MI: Last Name:* Address:* City:* State:* Zip:* Social Sec.: -- Date of Birth: // ADDITIONAL INFO Is this home a new purchase?Yes No Do you currently have a homeowner policy? Yes (please finish this section and go on to the next section) No (skip to the section "Property Info") If yes, what company? Expiration Date: // CURRENT COVERAGE
PROPERTY INFO If property address is different than the address entered above, please list it here: Address: City: State: Zip:
SECURITY FEATURES Central Alarm System: Monitored Not Monitored None Fire Extinguisher Smoke Alarm Dead Bolt Locks Interior Sprinkler OUTSIDE FEATURES
ANIMALS Do you have any animals? Yes No If yes, please list the types of animals: CLAIM INFO List any homeowner claims in the last 3 years: Have you filed for bankruptcy in the last 5 years? Yes No If there is any other information that you feel would be helpful, please enter it below: Please tell us how you heard about Key Insurance (check all that apply): Internet Yellow Pages Friend or family member Newspaper Ad Other (please enter here): Please enter your phone number and email address below. Then select how you would like for us to contact you. **NOTE: If you do not have an email address, you must select "I do not have an email address".** Phone (please enter here):* Email (please enter here):* I do not have an email address When you have completed the form, please or