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[contact-form][contact-field label=”First Name” type=”name” required=”1″ /][contact-field label=”Last Name” type=”text” required=”1″ /][contact-field label=”Your Email Address” type=”email” /][contact-field label=”Street Address, City, and State of Property to be Insured” type=”text” required=”1″ /][contact-field label=”$ Dollar Amount Dwelling is Insured for” type=”text” required=”1″ /][contact-field label=”Construction Type” type=”select” options=”Frame,Brick/Masonry,Log,Mobile Home,Earth Home” required=”1″ /][contact-field label=”The Age of Home or the Year is was originally constructed” type=”text” required=”1″ /][contact-field label=”Who Occupies the Dwelling?” type=”select” options=”Dwelling Occupied Full Time by Owner of the Home,Dwelling Occupied by Owner as a Seasonal or Part-time Home,Dwelling Occupied by a Tenant or Renter of the Home,Dwelling is Vacant or Unoccupied by Anyone At This Time” required=”1″ /][contact-field label=”Heating ” type=”select” options=”Dwelling is Heated with a Gas Furnace,Dwelling is Heated with an Electric Furnace,Dwelling is Heated with an Oil Furnace,Dwelling is Heated with a Wood Stove,Dwelling is Heating by Some Other Fuel or Method” required=”1″ /][contact-field label=”Fire Protection – Name of Responding Fire Department / District” type=”text” required=”1″ /][contact-field label=”Fire Protection – How Many Road Miles from Dwelling to Fire House” type=”text” required=”1″ /][contact-field label=”Roof – Roofing Materials” type=”select” options=”Composite or Asphalt Shingles,Metal Roof,Rolled Roofing,Architectural Shingles,Slate,Wood Shakes or Shingles,Other” required=”1″ /][contact-field label=”Electrical – Does Dwelling Have Adequate Circuit Breakers?” type=”select” options=”Yes,No” required=”1″ /][contact-field label=”Electrical – Does Dwelling Use Fuses?” type=”select” options=”No,Yes” required=”1″ /][contact-field label=”Policy Deductible” type=”select” options=”$1000,$2000,$2500,$5000″ required=”1″ /][contact-field label=”Sample Field Test” type=”checkbox” required=”1″ /][/contact-form]