The Homeowners Questionaire should be completed for the agent to evaluate your specific coverage needs.
NAME:
ADDRESS:
If you are satisfied with your current quote and do not want to purchase any optional coverages CHECK HERE and submit.
Otherwise, complete form in detail and submit.
Do you have any possible claims or problems with your home?:
Are you remodeling or plan to make any repairs or need to make any repairs to your home?:
Do you plan to sell your home in the near future?
Do you operate a business on your premises?
Do you own, rent or occupy any other residences?:
Do you own or keep any animals? What kind of animal?: If a dog, what breed? Mixed breed- list dominant breed?: Any biting history?:
Any coverage declined, cancelled or on-renewed during the past 3 years:
Any foreclosure, repossession or bankruptcy during the past 5 years?:
Do you own or rent any personal watercraft, jet ski, wave runner or similar watercraft?:
Do you own or rent a travel trailer, mobile home, recreational vehicle, motorized craft, aircraft ,watercraft or 4 wheeler?:
Is your home located on more than 5 acres?:
Do you own a farm, land or timber?:
If you have any of these Security/Protective device, please check them?
Double key deadbolts on all exterior doors
Smoke detectors
Local Alarm
Central Station Burglar Alarm*
Central Station Fire Alarm*
*Alarm Certificate is required from monitoring Company.
Have you had any insurance claims, losses or prior damage to your home?:
Please explain any yes answers to the above questions in the section below:
:
Optional Coverage Questions
Do you have any other household members not related or live in friends?:
Does your home have existing foundation damage?:
Do you own rental properties?:
Do you do volunteer work or maintain a public profile?:
Do you have any home day care, incidental farming operations, livestock, home office, studio, or residence employees?:
Do you belong to homeowners association?:
Do you want special glass coverage(2 story glass, leaded or expensive windows) for home?:
Home Updates
Roof Update:
ROOF UPDATE YEAR:
Hot Water Heater Update:
HOT WATER HEATER UPDATE YEAR:
Heating and A/C System Update:
HEATING AND A/C SYSTEM UPDATE YEAR:
Electrical System Update:
ELECTRICAL SYSTEM UPDATE YEAR:
Plumbing System Update:
PLUMBING SYSTEM UPDATE YEAR:
List any personal property you want special or scheduled coverage for, below:
JEWELRY Requested Jewelry Insurance Value:
Watches: Requested Watch Insurance Value:
Furs: Requested Fur Insurance Value:
Silverware: Requested Silverware Insurance Value:
Business Property (Tools or Merchandise): Requested Business Property insurance Value:
Collections: Requested Collections Insurance Value:
Fine Arts, Antiques, and Rugs: Requested Fine Arts, Antiques, and Rugs Insurance Value:
Water Craft: Requested Watercraft Insurance Value:
Musical Instruments: Requested Musical Instruments Insurance Value:
Camera and equipment: Requested Camera and Equipment insurance Value:
Sports Equipment: Requested Sports Equipment Insurance Value:
Golf Cart or Golf Equipment: Requested Golf Cart or Golf Equipment Insurance Value:
Low Power Recreation Vehicle:: Requested Low Power Recreation Vehicle Insurance Value:
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