Home Insurance Questionnaire Form
Name of Insured(s): List all people on title of the property
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
#2 Name of Insured(s): List all people on title of the property
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
#3 Name of Insured(s): List all people on title of the property
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
#4 Name of Insured(s): List all people on title of the property
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Location Address of Home
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Adress
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Has your address changed in the last 3 years?
*
Yes
No
If yes, please provide your previous address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How many years have you resided at your previous address?
*
How many years have you had continuous home insurance?
*
Any claims in the last 5 years?
*
Yes
No
If yes, you had a claim, please explain
Name of Mortgagee
*
Current Policy Number (if applicable)
Policy Expiry Date
-
Month
-
Day
Year
Date
Purpose of property?
*
Please Select
Primary
Rental
Other (please specify)
Other
Please specify the purpose of property
Dwelling Information
Any Business Activities on the premises?
*
Please Select
Yes
No
Other (Please specify)
Other
*
Please specify the Business Actvity
What year was the house built?
*
Number of Families?
*
Do you have a basement?
*
Yes
No
Square Footage of Basement
*
How many floors above ground?
*
Please Select
1
2
3
Square Footage of Upstairs
*
Total Square Footage of Home
*
Exterior Finishing of Home
*
Stucco
Vinyl Siding
Stone
Brick
Hardi-Plank
Other (Please specify)
Other
*
Please specify exterior finishing
Exterior Finish Percentage? (Please enter value '0' in empty boxes)
*
Type of Roofing
*
Please Select
Asphalt Shingle
Wood
Concrete
Metal
Tar Gravel
Torch On
Other (Please specify)
Other
*
Please specify type of Roof
Type of Heating?
*
Please Select
Forced Air Natural Gas
Radiant
Baseboard
Electric
Other (Please specify)
Other
*
Please specify type of Heating
Number of Kitchens?
*
How many Full Bathrooms?
*
How many Half Bathrooms?
*
Interior Floor Finish in Percentage? (Please enter value '0' in empty boxes)
*
How many Fireplaces?
*
Garage Type?
*
Please Select
Built in
Detached
Attached
No Garage
Size of Garage?
*
In sqft
Do you have a Porch/Deck?
*
Yes
No
If yes, how many square feet is your deck/porch?
*
In sqft
Type of Fireplace?
*
Gas
Wood
Electric
Do you have an Alarm?
*
Yes
No
Is your Alarm Local or Monitored?
*
Local
Monitored
Number of Rental Suites?
*
Does each suite have its own entrance?
*
Yes
No
Electrical Type?
*
Please Select
Copper
Aluminum
Breakers
Fuses
Any Pets?
*
Yes
No
Earthquake Coverage
*
Yes
No
Will you be willing to recommend me?
*
Yes
Maybe
No
Please give reference of any two people whom you feel:
Rows
Full Name
Address
Contact Number
1
2
Submit
Should be Empty: