Harmon-Gilmore Insurance
& Bonding Agency
Property Insurance - Dwelling

Name

Address

City

State

AL AK AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip

Email
Fax #		Home #

Type:	House Apartment Condominium Unit Townhouse	Rental	Yes No	Occupancy	Primary Secondary

Location:     Address		County		Subdivision
City		State	AL AK AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Construction:   Wall Construction   Frame Brick Veneer Frame Stucco Masonry Concrete

Roof

Tile Cedar Shingles Steel Concrete

Stories

1   2   3   4  High Rise

Date Built

Condominium:      Condo name:

Number of units in building:

Your Unit #

Bldg #

Protection:    Responding Fire Dept:

Miles:

	Hydrant 1,000 ft:	Yes No	Sprinklered:	Yes No
	Retired:	Yes No	Secured Community:	Yes No
	Certified Shutters:	Yes No	Dead Bolt:	Yes No
	Paved Road:	Yes No	Neighbor within eyesight:	Yes No
	Alarms:	Burglar Fire Burglar & Fire None
Flood     Zone:	V* A* B C X	* Elevation:	ft.

Coastal Barrier Island Area:

Yes No

Distance to water:

Feet Miles

Values:   Bldg. $		Contents $		Detached Bldg $

Condo Unit Only:   Additions and Alterations $

Loss Assessment $

Liability:

100,000 300,000 500,000

Dogs:

Yes No

Breed:

Prior Losses:    List all losses within the past 3 years	No Prior Losses
Remarks:

     

               
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