Wedgwood Insurance

Home Information :
Where is the Home Located?:
Any Claims in the last 5 Years?	Yes No
Ever been cancelled or renewal refused by an INs. Co. within last 5 yrs?
	Yes No
When does your present policy expire?
What is the age of your home?
If it is over 25 yrs old have any of the following been up-dated? When?
Roof?
Heat?
Electrical?
Plumbing?
Is the home Attached?	Yes No
How Many Sides?
How Many Stories?
Is there an Apartment?	Yes No
Is the home occupied?	Yes No
How Many Families?
Type of Roof Covering?
Type of Foundation?
Square Footage of Main Floor?
Finished basement/rec room Size?
Three Wall addition/attic size?
Porch or Deck Size?
Number of Bathrooms?	Full Half
Whirlpools or Saunas?
Built in Ovens?
Built in Stoves?
Central vacuums?
Air/Heat Exchangers?
Alarms?
SkyLights?
Is there a Garage?	Yes No
Is the Garage Attached?	Yes No
Number of Cars?
Is there a Swimming Pool?	Yes No
Is it above ground?	Yes No
Size of Pool?
If in ground:	Reinforced Concrete Fiberglass Vinyl Fiberglass
Main Source of Heat?
Is there a wood stove?	Yes No
Is there a chimney?	Yes No
Professionally installed?	Yes No
Is there a fireplace?	Yes No
Type of fireplace?
Chimney?
If brick, is it Lined?	Yes No
Is there an oil tank on premises?	Yes No
Outside?	Yes No
Age?
Above Ground?	Yes No
Vented?	Yes No
Distance to nearest hydrant?
Distance to nearest fire hall?
Any Business activity conducted on premises?	Yes No
Region:	Avalon Central Western
Personal Information :
Name :
Telephone :
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