Home Insurance Inquiry Form
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you lived at the current address for less than 6 months?
Yes
No
If Yes, please provide prior address.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Second Named Insured (optional)
First Name
Last Name
General Info
Who lives at this dwelling?
Tenant
Myself
How many people occupy this dwelling?
Do you have a swimming pool?
Yes- with yard or pool fenced
Yes- with neither yard or pool fenced
No
Highest Level of Education in Household
Associate or Trade School
College Degree
Associate Degree
High School or GED
No High School
Other
Occupation
Sales, Beautician, Construction, Health Care, etc.
How did you hear about us?
What type of fuel is used in your heating system?
Electricity
Oil
Coal
Gas (Public)
Gas (Tank)
Solar
Wood
Other
What year was the roof installed or updated?
end
Discounts
Do you have an Auto policy with us?
Yes
No
Do you have a Life policy with us?
Yes
No
Do you have an automatic sprinkler system?
Yes - Full
Yes - Partial
No
Do you have a home security system?
Yes: Self-monitored
Yes: Professionally monitored
No
Do you have a smoke and fire monitor?
Yes: Self-monitored Nest
Yes: Self-monitored Other
Yes: Professionally Monitored
No
Do you have a water sensor
Yes: Self-monitored
Yes- Professionally Monitored
No
Does your water sensor have a shut-off valve?
Yes
No
N/A
Do you have a wifi-enabled smart thermostat?
Yes
No
Do you have any galvanized or polybutylene (PB) plumbing?
Yes
No
Has your home received certification from the Institute for Business and Home Safety (IBHS) as a part of their FORTIFIED program?
Yes
No
Electrical- Year Updated
mm/yyyy
Plumbing- Year Updated
mm/yyyy
Heating-Year Updated
mm/yyyy
Current Insurance Provider
Please list any animals you have.
Do you have a trampoline?
Yes
No
Do you ever rent out your home or a part of your home for more than a total of 30 days per year?
Yes
Yes, but not more than 30 days per year
No
By completing this form, you acknowledge that we may review your credit report or obtain or use a credit-based insurance score based on the information contained in that credit report. We may use a third party in connection with the development of your insurance score.
I acknowledge and accept these terms.
End of Form
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