Ruhl & Ruhl Insurance

Homeowners

Please fill out this form, complete as much information as possible.

Location and Legal Description of Property if Different than Mailing Address
Address
City	State	Zip code

Coverages and Limits of Liability

Dwelling	Other Structures
Personal Property	Loss Use
Personal Liability	Medical Payments
Deductible
Scheduled Items: Jewerly/Furs/Antiques Value

General Information, Property Coverage and Rating Information
Construction
Year Built	Year Renovated	Square Feet
Stories	No. of Families
Residence Type	Within City Limits? yes no
Exterior Wall Category	Substructure
Occupancy	Residence Ground Floor Area sq. ft.
Fire Alarm	Smoke Detector	Burglar Alarm
Business on Premises (including Daycare)? yes no
Auxiliary Heating
Fireplace yes no	Fireplace Insert yes no	Prefab Fireplace yes no
Wood stove yes no	Solar Heating yes no	Wood/Coal Furnace yes no
Pellet yes no
Fireplace/Stove professionally cleaned annually? yes no
Finished Attic yes no	sq. ft.
Walk-out Basement yes no	sq. ft.
Finished Basement yes no	sq. ft.
Breezeway yes no		sq. ft.
Porch		sq. ft.
Balconies or Deck yes no	sq. ft.
No. of Bathrooms
Full Half
Garages	sq. ft.
Air Conditioning yes no
Room Additions Above Garage sq. ft.
3-wall Additions	sq. ft.

Property and Liability Loss Information
Any Losses Last 5 Years yes no If yes, explain: Date, Type of Loss, Description and Amount of Loss.

Additional Underwriting Information
Pets yes no Breed of Pet	Day Care/Child care? yes no