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	Construction: Frame Brick (click one) Deductible: $250.00 $500.00 $1,000.00 Other Age of Home: Dwelling Coverage:(replacement cost of home) You Might be eligible for a Mature Homeowner Discount Age of Husband: Age of Wife: Are you within 1,000 feet of a Fire Hydrant: yes no Approx Distance from Fire Department: Do you have? Deadbolt Locks: yes no Smoke Detectors: yes no Fire Extinguisher(s): yes no Burglar Alarm: yes no (if YES is it central station or reports directly to Police and Fire Department) yes no Swimming Pool: yes no Fenced Yard: yes no In the LAST five years have you: Bankruptcies (except medical bill documentation) yes no Judgements: yes no Foreclosures: yes no Repossessions: yes no Claims For Damages To Your House: yes no (if yes briefly explain below) Who are you currently insured through: Are there any items to schedule, such as: jewelry, fine art, furs, guns, equipment, etc?yes no If yes, briefly list: If you need help or additional information about this form, please call us a (256) 232-3310 or e-mail us at: sales@richardsonanddeemerinsurance.com