Illinois Alliance Insurance

HOME INSURANCE INFORMATION SHEET

Please fill in the information below and use the submit button to send to our office. This information is sent via a secure server to protect your privacy. If you prefer, you may print this form and mail it to the address below. NOTE: All Fields Are Required.


Name		Spouse's Name
Date of Birth		Date of Birth
Social Security #		Social Security #
Occupation		Occupation
Address		City	State
Zip Code		County
Daytime Phone		Cell Phone
E-mail		Deeded in your name? Yes No
Dog(s)? Yes No	Breed(s)	Bankruptcy in past 5 years? Yes No

Distance to Fire Department miles

Year Built

Year Purchased

Construction

Style

Square Footage

Garage

Size

Finished?

Foundation

Fireplace

Ext. Walls

Wall Finish

Type of Roof

Ceiling

Baths

Full

Half

Outbuildings

Deck

Sq. ft?

Heating

Air Conditioning

Swimming Pool

Porch

Sq. ft.

Basement

Skylights

Basement Sq. ft. finished

Updates	Plumbing	Year		Wiring	Year
Updates	Roof	Year		HVAC	Year

Building Details
Floors - please choose percentage for each		Finished Attic: Yes No	Finished Sq. ft.
Carpet, Acrylic	Ceramic Tile	French Doors (count each)
Carpet, Wool/Berber	Marble	Spiral Staircase
Hardwood	Vinyl	Business/Office on Property?	Yes No
Laminate	Concrete	Details:
Parquet	Rubber

Click the box in front of any of the following that you have:
Central Vacuum	Solar Heat	Hot Tub	Intercom
Sauna	Sprinker System	Burglar Alarm	Jacuzzi
Stained or Varnished Woodwork	Hardwood, Slate, Marble or Quarry Tile Floors		Brick or Stone Walls >50%
RV, ATV, Golf Cart, Snowmobile	Computer	Custom Installed Vanity	Elevator
Satellite Dish	Wet Bar	Cabana	Gazebo
Built-In Barbeque	Basketball Court	Trampoline	Lift Chair or Wheelchair Lift
Boat

Do you have any of these special features? Check all that apply.
Den	Exercise Room	Laundry Room	Rec Room
Office	Formal Dining Room	Large Foyer	Study
Library	Cathedral Ceilings >70 ft.	Great Room	Family Room
Type details here:

If you have any of these BUILT IN , please use the drop down list to indicate the quality:
Air Conditioner	Air Filter	Carbon Monoxide Detector
Air Exchanger	Elevator	Roof Exhaust Fan
Humidifier	Garage Door Opener	Sauna
Bathroom Heater	Hot Tub (not jetted tub)	Trash Compactor
Refrigerator	Intercom System	Video Door Answering System
Ceiling Fans	Sprinker System	Washer
Central Vacuum	Jetted Tub	Water Purification System
Countertop Range	Microwave	Water Softener
Dishwasher	Oven	Wet Bar
Water Heater	Fireplace insert	Whole House Fan
Dryer	Range Hood



Current Policy #	Dwelling Replacement Cost (on existing policy)
Current Company	Cancelled or Non-Renewed in past 5 years?	Yes No
Claims in Last 5 years? Yes No	Auto Company
If yes, please explain:	Renewal Date
	Current Liability Limit $
	Current Policy #

Mailing Address for Form:

Kathy Backhaus
Illnois Alliance Insurance
4915 W. Elm Street, Suite C
McHenry, IL 60050