Tell Us About Your Home

1. What is your physical address (Street Address)

2. What is your name?

3. What type of house is it?
Select One... Ranch Cape Code Bi-Level Regular 2 Story Regular Story with Basement Other
If other, please specify:

4. Number of Bedrooms?
Select One... 1 2 3 4 5

5. Number of Floors:
Select One... 1 2 3

6. What type of roof material:
Select One... Shingles Tin Wooden Shingles Other
If other please specify:

7. Do you have a Basement?
Yes No

8. Do you have a garage?
Yes No
If yes is the garage attached to the house?
Yes No

9. Do you have working smoke alarms?
Yes No

10. How many people live in the household?
Select One... 1 2 3 4 5 6 7 8

11. Do you have a driveway leading to your house?
Yes No
If yes, approximately how long is the driveway?

12. What type of heat do you have?
Select One... Electric base board Oil hot water Gas Woodstove

13. What is the nearest cross Streets to you?

14. Do You have a water source near you? (Example Pond, Stream, swimming pool)
Yes No

If yes, How close to your house is it.?

15. Is there anything else we should know about your property?