International Insurance of Georgia (IIG)

Homeowner/Dwelling Application

Homeowner/Dwelling Application
General Information
Applicant's Name:*
Street Address:*
City/State/Zip:*	City: State: ZIP:
County:
Current Address (if not same as above):
City/State/Zip:	City: State: ZIP:
County:
Phone Number:
E-Mail Address:
How did you find us?:

Property Information
Closing/Purchase date:
Year built:
# of stories:
Living area (Sq. Ft.):
Basement:	Yes No
Basement (Sq. Ft.):
Basement finished percentage:
# of bathrooms:
# of fireplaces:
Floor - % hardwood:
Floor - % carpet:
Floor - % tile/vinyl:
Central burglar/fire alarm:	Yes No
Any pets with bite history:	Yes No
If yes, Type of animal:
Garage (Built in/ Attached):
# of cars garage:
Exterior wall type:
Deck (Sq. Ft.):
Porch (Sq. Ft.):
Year renovated:	Plumbing Heating Electrical Roof

Name of carrier:

Expiration Date:

Years insured with current carrier?

Prior home value insured?

Current deductible

Loss History in the past 3 years

Month/Year

Type of Loss

Explanation