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Personal Insurance Questionnaire
Contact Information
First Name
*
Last Name
*
Mailing Address
*
Address Line 2
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Phone Number
*
Email Address
*
Upload copy of all insurance policy declarations page(s) and any other relevant or requested documents.
*
The information on the remaining pages is optional. It will help expedite the process.
Homeowners Coverage
How many properties would you like to insure?
1
2
3
4
Homeowners Coverage - Property 1
Current Carrier
*
Expiration Date
*
+
Property Address
Prior Address (if lived at property address for less than six months)
Purchase Date
+
Historically Registered Home?
Yes
No
Usage?
Primary
Secondary
Seasonal (inoccupancy 60+ days)
Rented to others and # of weeks rented
Rented to others and # of weeks rented
Is the home deeded in the name of an LLC or Trust?
Yes
No
In what year was the home constructed?
What is the area (in square feet) of the home?
Is there a fire hydrant located within 1,000 feet of your home?
Yes
No
What is the construction type of the exterior walls of the home?
Masonry
Frame
Stucco
Brick Veneer
Brick Veneer
What is the roofing material of the home?
Composite shingle
Wood shake
Slate
Tile
Tile
What foundation type supports the home?
Basement
Crawl
Slab
If basement, what percentage finished?
Heat source?
Gas
Electric
Oil
Other:
Other:
System Updates
Please provide year of renovation/update if applicable
HVAC System
Please provide year of renovation/update if applicable
Roofing
Please provide year of renovation/update if applicable
Plumbing System
Please provide year of renovation/update if applicable
Electrical System
Please provide year of renovation/update if applicable
Risk Mitigation Devices and Other Credits (please indicate if the home is equipped)
Monitored burglar and fire alarm
Yes
No
If alarmed, Cellular Back up
Yes
No
Monitored low temperature alarm
Yes
No
Water flow or leak detection system
Yes
No
Back up power generator
Yes
No
Gas leak detection or seismic gas shut off system
Yes
No
Perimeter gate or surveillance system
Yes
No
Located in a guard gated community
Yes
No
Property caretaker
Yes
No
Sump Pump
Yes
No
Back up power?
Battery
Gas
Other:
Other:
Additional Information (please indicate any special or custom features here)