Name

Address

Address Line 2

City

State MN

Zip Code

Telephone

Email Address

1. Year the dwelling was constructed .

2. Dimensions or Sq. Feet.

3. Replacement cost of dwelling if known $.

4. Amount of insurance coverage requested on dwelling $.

5. Distance from fire department miles.

If the dwelling has been renovated in the past 25 years indicate the year each renovation was done:

6. Year Electrical - Complete wiring replacement.

7. Year Plumbing - Replacement of all piping, valves, fittings and fixtures.

8. Year Heating - Replacement of hot air, hot water or steam heating systems.

9. Year Roofing - Replacement of all roofing materials.

Please check any of the following you own:

Snowmobile

Boat

Golf Cart

Jewelry -  value $