Contact information
		* First Name
		* Last Name
		* Street Address
		* City
		* Sorry, but we currently only accept applications for Illinois residents.
		* Zip
		* Email
		* County
		* Phone (Day)
		Phone (Evening)
		Fax
	/ /	What is your Birth Date (mm/dd/yyyy)
		Occupation
	When would you like to be contacted?
	Morning Afternoon Evening Everytime
	Any Comments / Questions?
	Is this insurance quote for Homeowners Renters Condo Multi-Unit
	Do you currently have home Insurance?
	Yes No
		If "Yes", when does your current policy expire?
		If "Yes", who are you currently insured with?
		If "Yes", how much is your home insured for?
		Year Purchased
		Purchase Price
		Loan Amount
		Approximate Interior Square Footage
		Approximate Year Built
	Is your home located within 500 feet of a fire hydrant?
	Yes No
	Is your home located within 5 miles of a fire station?
	Yes No
	Is your home susceptible to flooding or high water?
	Yes No
	Do you have a dog?
	Yes No
		If "Yes", what kind of dog ?
	Is there a central alarm system?
	Yes No
	Have you experienced any losses or filed any claims within the last 5 years?
	Yes No
	Please provide the dates and type of loss
	Number of Stories 1 2 3 4 5 6 >6
	How many rooms 5 6 7 8 9 10 11 12 13 14 15
	Do you have a basement? No Basement Unfinished Partly Finished Fully Finished Slab Crawl Space Other
	Do you have a garage? No Garage Carport Attached One Car Attached Two Car Attached Three Car Unattached One Car Unattached Two Car Unattached Three Car Other
	Do you have a pool? No Above Ground Below Ground Other
	How many bathrooms? 1 1 1/2 2 2 1/2 3 3 1/2 4 4 1/2 5 5+
	How many bedrooms? 1 2 3 4 5 5+
	How many fireplaces? 0 1 2 3 4+
	Type of exterior wall Adobe Aluminum/Vinyl Siding Asphalt Brick Veneer Cement Fiber Clap Board Concrete Block Log Siding Logs Mineral Fiber Painted Masonry Precast Concrete Precast Stone Slump Block Split Block Solid Brick Solid Stone Stone Veneer Stucco on Frame Stucco on Masonry Wood Shakes Wood Siding Other / Not Sure
	Type of roof Architectural Shingles Asphalt or Fiberglass Shingles Built-Up/Tar and Gravel Clay Tile Concrete Tile Corrugated Steel Mineral Fiber Shakes Mission Tile Rock Roof Roll Roof Rubber Roof Slate Tin Wood Fiber Shingles Wood Shake Other / Not Sure
	Age of Roof? 1 year old 2 years old 3 years old 4 years old 5 years old 6 - 10 years old 10 - 15 years old 15 - 20 years old 20 -25 years old 25 - 30 years old 30+ years old
	Type of foundation Crawl Space Slab on Grade Basement Walkout Basement Other / Not Sure
	Rate your own credit Excellent Minor problems Bad Horrible