Home Insurance Questionnaire

Please fill out as thoroughly as possible so we can provide you with an accurate Quote.

Please complete the form below

Basic Information

Name

First Name

Last Name

Best Phone Number to Reach You

(###)

###

####

Your Date of Birth

YYYY

Email Address

Spouse Name

First Name

Last Name

Spouse Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Occupancy

Any Extra Information on Type of Occupancy of the Home

Who lives at the home?

Year Built

Style (Ranch. Colonial, Cape, etc...)

Square Feet of Home

Section 2 Current Coverage Information

A) Dwelling Amount-

B) Other Structure Amount-

C) Personal Property Amount

E) Liability Amount

F) Medical Payments Amount

Do You have a Finished Basement? If So Square Footage?

Do You have a Sump Pump?

Policy Deductible

Any Claims in the Last 3 Years if so when and what ocurred?

Do you have a Security System?

Smoker or Non-Smoker

Current Company Your Coverage is with

When is the Expiration Date of Current Coverage

YYYY

Are you being renewed

Home and Auto With Same Company?

Do You have Umbrella Coverage

Wood Burning Stove or Fireplace Inspected

Is your Electricity Amperage over 100 Amp with Circuit Breakers

Plumbing

Last Roof Update (Estimate)

YYYY

Location of Oil Tank.

Want to make sure not buried.

Any Dogs

Type of Dogs (any incidents , re:bites)

Swimming Pool or Hot Tub?

Swimming Pool

Hot Tub

Neither

Trampoline

Currently Have/ Required Flood Insurance

Do You have any Scheduled Propery (Jewelry, Paintings etc...) If so how much is it insured for?

Supplemental Home Template

How Many Stories

How Many Bedrooms

Foundation (Basement, Slab, Crawl Space etc...)

Exterior Walls (Vinyl Siding, Wood, Brick?)

Kitchen Info

Basic Kitchen, Custom etc...?

Baths

Bedrooms

Other Rooms In The House

Attached Structures (Deck, Porches etc...)

Attached Garage (How Many Car Garage)

Detached Structures (Sheds etc...)

Partition Walls (Drywall, Plaster)

Wall Finish (Paint, WallPaper, Panel, Mix etc...)

Central Air

Heating Source. (Oil, Gas, Propane)

Type of Heat (Baseboard, Forced Hot Air, other)

Central Vac

Heated Floors

Do You have AAA?