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Date

How did you hear about us?

Phone

Owner(s)

Date of Birth

Address

Address INSIDE park

Closing Date/Purchase Date

Current Insurance

Exp/CX Date

Claims last 3 years

CX Reason

Cross Street

Park Name

Gated

Type

Own Lot

Manager or Assn

Subdivision: # Manuf. Homes in Neighborhood

Private Property: Size of Property

# Homes in Area

Hydrant (ft)

Fire Station (mi)

Fire Ext.

Smoke Det.

Months Owner Occupied

Months Rented

Home Watch

Other State/Country

Central Alarm

Shutters

Year Built

Length

Width

Bedrooms

Bathrooms

Skirting

Air Conditioning

Roof Units #

Wall Units #

Window Units #

Lanai/FL Room Size

Raised

Car Port Size

Shed/Utility Rm Size

Attached

Wood Deck Size

Awnings Sizes & Numbers

Types

Rooms Additions Tip-Outs

Framed

Masonry

Patios

Covered

Open

Fire Place

None

Above Ground

In Ground

Fenced/Screened (ft)

Diving Board/Slide

Shingles or Roof Over

Homesteaded

Dwelling

Contents

Liability

Scheduled Items

Golf Cart Coverage

Pet's Number and Breed

History of Attack or Guard Dog

On Water (Gulf, River, Lake, Pond, Canal, etc)

Distance (ft)

Flood Zone

Wind Pool Area

Mortgage

Escrowed

Credit OK?