Homeowners Insurance

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Kohn Wealth Management Advisors, LLC

9078 Union Centre Blvd., Suite 350

West Chester, OH 45069

Phone: 513-563-3469<br> Mobile: 513-543-1673

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Fax: 888-522-7916

www.kohnwealth.net

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garry@kohnwealth.net

This information is designed to provide a general overview with regard to the subject matter covered and is not state specific. The authors, publisher and host are not providing legal, accounting or specific advice to your situtation.

Securities and Investment Advisory Services offered through L.M. Kohn & Company, a Registered Broker/Dealer, Member of FINRA/SIPC/MSRB. 10151 Carver Road, Suite 100, Cincinnati, OH 45242. 800-478-0788. Affiliated with all major exchanges.

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» Name:
Address:
City:
State:
Zip:
» Home Phone:
Work Phone:
» Email:
Age:

Insurance Type:	Single Family Townhouse Condo Renters
If multi-family bldg, how many residential units:	1-4 5-12 12+
Construction Type:	Frame Masonry Masonry Veneer
Year Built:
Nearest Fire Hydrant:	under 1000 feet none
Nearest Fire Department:	1 2 3 4 5 5+ miles
Smoke Detector:	Yes No
Deadbolt Locks:	Yes No
Fire Extinguisher:	Yes No
Central Station Fire Alarm:	Yes No
Central Station Burglar Alarm	Yes No
Swimming Pool:	Yes No
If yes, is it fenced in:	Yes No
Wood Burning Stove:	Yes No
Do you have a dog:	Yes No
Market Value $:
Existing dwelling coverage amount $:
Desired Coverage Amount $:
Liability Limit $:
Deductible:	250 500 1000
Any special coverages:
Current Insurance Company:
Expiration date (or settlement if new purchase):
Any claims past 5 years:
Please use the space below to add comments regarding any special circumstances.