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Personal Information
Name
Date of Birth
Spouse Name
Date of Birth
Address
City
State	Illinois Wisconsin
Zip
Telephone
Current Coverages
Current Insurance Company
Expiration Date
Dwelling Amount
Deductible	500 1000
Liability	300,000 500,000
Medical Payments	1,000 2,000 5,000
House Information
Construction of Home	Frame Brick Veneer Masonry
Year Built
Number of Stories	1 1-1/2 2
Ground Floor Square Feet
Total Square Feet
Bathrooms	1 2 3
Half bathrooms	1 2
Basement	Yes No
Finished?	No Yes Partial
Garage	1 Car 2 Car 3 Car
Garage Type	Attached Detached
Outbuildings
Utilities
Heat	Gas Forced Air Electric Boiler Hot Water
Year updated
Electrical	Circuit Breakers Fuses
Year updated
Central Air?	Yes No
Year updated
Type of Roof
Year updated
Plumbing
Year updated
Safety Features
Dead Bolt Locks?	Yes No
Fire extinguisher?	Yes No
Smoke Detectors?	Yes No
Distance to Fire Hydrant
Name of Fire Department
Number of fireplaces	0 1 2 3
Same Chimney?	Yes No
Type of Fireplace	Gas Wood
Wood Burning Stove?	Yes   No
Porches or Decks?	Yes No
How Many?	Yes No
Total Square Feet
Swimming Pool?	Yes   No
In-ground?	Yes   No
Above Ground?	Yes   No
Scheduled Items?
Jewelry	Yes   No
Furs	Yes   No
Silverware	Yes   No

Pardridge Insurance, Inc.

2580 DeKalb Ave.
Sycamore, IL 60178
Phone: (815) 758-4447
Toll Free: (877) 787-4447
Fax: (815) 758-3111
Hours: 8 a.m. to 5 p.m. Monday through Friday
E-mail: info@pardridge.com