Home Owners Insurance Questionnaire
Information Confidential for Quoting Purposes Only
Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Are you the applicant? If not, please input your name and relationship to applicant
Date of Birth
Type of residence
HO3 - Standard homeowners
HO4 - Renters policy
HO6 - Condo/Townhouse policy
Is insurance needed for a closing?
Yes
No
Closing date or proposed start date
-
Month
-
Day
Year
Date
Are you the applicant? If not, please list your name and relationship to the applicant
Underwriting Questions
Year built
Type of construction
Frame
Mason
Other
Type of roof
Garage
Yes, detached
Yes, attached
No
Heating source
Gas
Electric
Oil
Other
Trampoline
Yes
No
Type a question
Yes, with fence
Yes, without fence
No
Wood Stove
Yes
No
Fireplace
Yes
No
Home business, if yes please describe
Miles to nearest firestation
Feet to nearest hydrant
Deducible
250
500
750
750
1000
2500
Claims in the last 3 years
Yes
No
If "Yes," please describe
Additional Coverages
Additional Coverages Requested (select all that apply)
Sinkhole
Equipment Breakdown
Earthquake
Flood
Water backup
Identity Theft
Additional needs or concerns with y
our policy
Scheduled personal property, if any (ex. engagement ring, fine china)
Description
Value
Appraisal Date
Item #1
Item #2
Item #3
Item #4
Additional information, questions, or concerns
Preview PDF
Submit
Should be Empty: