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Home Owners MAP
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Name
*
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*
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*
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*
* Name and email optional if previously completed Mosher Assessment Process
WERE YOU REFERRED BY AN AGENT?
*
Yes
No
AGENT'S NAME
*
Next
ARE YOU IN A FLOOD PLAIN?
*
YES
NO
YEAR BUILT
Selected Value:
1875
TYPE OF HOME, i.e. ranch, cape cod, two-story etc.
*
Previous
Next
HOME SQUARE FOOTAGE
Selected Value:
500
DO YOU HAVE A POOL?
*
YES
NO
FENCE
DIVING BOARD
SLIDE
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Next
Age of Roof
Selected Value:
1
TYPE OF ROOF
*
ELECTRICAL SYSTEM
*
FUSES
CIRCUIT BREAKERS
MINIMUM 100 AMP SERVICE?
*
YES
NO
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Next
DO YOU CURRENTLY HAVE FLOOD INSURANCE?
*
YES
NO
IS HAVING FLOOD INSURANCE IMPORTANT TO YOU?
YES
NO
DO YOU CURRENTLY HAVE EARTHQUAKE INSURANCE?
*
YES
NO
IS HAVING EARTHQUAKE INSURANCE IMPORTANT TO YOU?
YES
NO
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Next
CURRENT INSURANCE PROVIDER
*
RENEWAL DATE
*
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Next
TYPE OF CONSTRUCTION?
*
TYPE OF SIDING?
*
FIRE PLACE?
*
YES
NO
HOW MANY?
*
1
2
3
4
5
WOOD
GAS
PELLET
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Next
DO YOU HAVE A PORCH?
*
YES
NO
SQUARE FOOTAGE
Selected Value:
100
DO YOU HAVE A DECK?
*
YES
NO
SQUARE FOOTAGE
Selected Value:
100
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Next
DO YOU HAVE A BASEMENT?
*
YES
NO
SUMP PUMP?
*
YES
NO
DOES IT HAVE A WALKOUT?
*
YES
NO
PERCENT FINISHED
Selected Value:
0
OTHER STRUCTURES? (detail and usage)
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Next
HEATING SYSTEM
FURNACE TYPE
*
NATURAL GAS
WOOD
PELLET
OIL
Primary
AGE
Selected Value:
1
DO YOU HAVE A SECONDARY FURNACE SYSTEM?
*
YES
NO
SECONDARY HEAT SOURCE
FURNACE TYPE
*
NATURAL GAS
WOOD
PELLET
OIL
Alternate
AGE
Selected Value:
1
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IN-HOME BUSINESS? If so, please describe.
DO YOU HAVE A MORTGAGE?
*
YES
NO
LENDER
*
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SCHEDULED PERSONAL PROPERTY
ANYTHING CUSTOM OR UNIQUE?
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SUBMIT