Homeowners Questionnaire Referred By: Date: New or Renewal New Renewal Insured Name (#1) Date of Birth (#1) Social Security # (#1) Occupation (#1) Education Level (#1) Insured Name (#2) Date of Birth (#2) Social Security # (#2) Occupation # (#2) Education Level # (#2) Email Phone Number Text? Yes No Mailing Address Policy Effective Date Location Address: Purch. Date Prior Address: Prior Purch. Date Current Insurance Carrier: How Long: Exp. Date Billing Preference: Monthly Quarterly Semi-Annual Annual Billing Type Escrow Auto Withdrawal Mail Would you like Electronic Docs? Policy Type Home Condo Renters Secondary Home Property Type Bi-Level Bungalow Cabin Cape Cod Colonial Craftsman Farmhouse Mansion Modern Ranch Split-Level Townhome Tudor Victorian Unique Is Property Rented? Short-Term Long-Term None Is Home under const.? Who is Home Deeded to? Who lives here? Year Built: Sq. Ft.: # Stories: # Bedrooms: # Bathrooms: Construction Type Frame Brick-Veneer Masonry Metal Frame Post Frame Other Siding Type Brick Cement Fiber Concrete Block Log Metal Stone Stucco Wood Wood Shake/Shingle Vinyl Other Roof Type: Architectural Shingle Asphalt Shingle Built-Up Clay Tile Concrete Concrete Tile Living (Green/Moss/Plant) Membrane Metal Rolled, Slate Synthetic Slate Wood Shake/Shingle Other Last Year Roof Updated: Roof Update Full Partial HVAC Type: Electric Geo-Thermal LPG Natural Gas Oil Solid Fuel (Wood, etc.) Other Last Year HVAC Updated HVAC Update Full Partial Electrical: Do you have Knob & Tube or Aluminum Wiring? Electrical: Do you have a Federal Pacific, Zinsco, Sylvania, or ITE-Pushmatic Breaker Box? Last Year Electrical Updated: Electrical Update Full Partial Last Year Plumbing Updated Plumbing Update: Full Partial Plumbing: Do you have Cast Iron, Clay, Polybutylene, or Galvanized Pipes? Unique Home Finishes Kitchen Grade Basic Builders Grade Semi-Custom Custom Luxurious Bathroom(s) Grade Basic Builders Grade Semi-Custom Custom Luxurious Type of Foundation Slab Crawlspace Poured Concrete Basement Poured Concrete Basement w/ Walkout Block Basement Block Basement w/ Walkout Other Basement Finish %: # & Type of Fireplaces: Type of Garage: Attached Basement Built-in Carport Detached Other Garage Size: 1 1 ½ 2 2 ½ 3 3 ½ 4 4 ½ 5 Deck or Porch? Pool: Aboveground Inground None Fenced and/or Ladder Locked? Yes No Security System / Water Shut off / Temp. Monitoring / Smart Alarms / Smart Home Devices / Etc.: Dog(s) (#, type, breed): Farm or Exotic Animals (# & type): Trampoline Yes No Netted and Inside Fence Yes - Both Yes - Netted No Acreage: Detached Structures (include type of building and size): HOA Name In Home Business? Own any Vacant Land? (need address, acreage, & use) Any Buildings Used for Business Use or Storage? Any Farming? Any Hunting? Any Claims in the Past 5 Years? (include date, what happened, and $ paid) Do you own a Recreational Vehicle? Do you own a Drone? Current Coverages Dwelling $ Other Structures $ Personal Property $ Loss of Use $ Liability $ Med Pay $ Deductible $ Water Back-Up $ Loss Assessment $ PERSONAL ARTICLES I have no Personal Articles Jewelry: Blanket: Scheduled: Fine Arts: Blanket: Scheduled: Collectibles: Blanket: Scheduled: Firearms: Blanket: Scheduled: Other: Blanket: Scheduled: ENDORSEMENTS Identity Theft: Yes No Earthquake: Yes No Sinkhole: Yes No Mine Subsidence: Yes No Water Seepage/Leakage: Yes No Service Line: Yes No Mechanical Breakdown: Yes No Refrigerated Products: Yes No Matching Siding/Roof/Etc.: Yes No Ordinance & Law: Yes No Guarenteed Dwelling RC: Yes No Personal Cyber: Yes No Home Sharing: Yes No Farm Liability: Yes No Rec. Vehicle Liability: Yes No Ext. Dwell. Liab. (need address): Yes No Home Under Construction: Yes No MORTGAGEE First Mortgagee Address Loan # Second Mortgagee Address Loan # Final Remarks Final Remarks (Need Quote for Life, Health, Business?) Attach Policy Dec Pages, Personal Article Appraisals, & any other useful information Send
