Home Insurance Questionnaire * = Required Contact Information Name* Phone* Email* General Information Location Address County of Residence Years at location Previous Address (If less than 6 Months) Phone # Mobile Phone # Date of Birth Social Security # Employer Occupation Co-Applicant Name Date of Birth Social Security # Has any coverage been canceled, declined or non-renewed within the last 3 years? NoYes Homeowners Home Information Is this a new purchase? NoYes Month/Year Purchased Current Insured Value (Replacement Cost) Liability Limit Requested Deductible Home Usage Primary ResidenceSecondary ResidenceRented to Others Year Built Square Footage # of Stories Construction Type Style Heat Type Alternate Heat Source NoYes Type (If yes) Fireplace(s) # Fireplace Type WoodGas Roof Material Roof Type PitchedFlat Protection Devices Smoke Alarm NoneCentralDirectLocal Protection Devices Burglar Alarm NoneCentralDirectLocal Sprinkler System NoYes Deadbolt Locks NoYes Circuit Breakers NoYes Fire Extinguishers NoYes Updates: Wiring Plumbing Heating Roof Basement NoYes If Yes: Finished NoYes Square Footage Swimming Pool NoYes Fenced(If Yes) NoYes Diving Board (If Yes) NoYes Type (If yes) No PoolAbove GroundIn-Ground Garage NoYes Type (If yes) No GarageAttachedDetached # of Cars Distance to Fire Department Distance to Hydrant Full Bathrooms (# by Type) Designer Standard Builder's Grade Half Bathrooms (# by Type) Designer Standard Builder's Grade Kitchen (# by Type) Designer Standard Builder's Grade Other Structures on Property NoYes Type (If yes) Additional Information Any farming or other business conducted on premises? NoYes Type (If yes) Any Residence Employees? NoYes If Yes: How Many FT PT Type Any other residence owned, occupied or rented? NoYes Any Pets? NoYes If yes: Type (If Dog, include Breed) Is property located on more than 5 acres? NoYes If yes: How many Does applicant own any recreational vehicles? NoYes If yes: How many Type(s) Is building undergoing any renovation or reconstruction? NoYes If yes: Describe Is there a trampoline? NoYes Is the property located in a Flood Zone? Mortgage Information 1st Mortgagee: Name of Mortgage Company Address Loan # Is mortgage escrowed? NoYes 2nd Mortgagee: Name of Mortgage Company Address Loan # Is mortgage escrowed? NoYes Valuable Items/Collections Jewelry Total Value Furs Total Value Fine Arts Total Value Firearms Total Value Silverware Total Value Other (Describe) Description of Other Loss History Date of LossDescriptionAmount Paid Prior Carrier YearInsurance CompanyAnnual Premium Notes
