Do you have a fireplace? Yes     No

Where is the nearest fire hydrant?
(Required Field)
 Less than 500 feet
 500ft to 1000ft
 Over 1000ft
 None in Neighborhood

How far is the nearest fire station?
(Required Field)
 Less than 1 mile
 2-3 miles
 3-5 miles
 Over 5 miles

Do You Own a Dog?     Yes     No     
If yes, what type(s)?:  

Do You Have a Pool? Yes   No     If yes, is it fenced in?: Yes   No

Do You Do Business Out of Your Home?     Yes   No   
If yes, what kind?: