Homeowners Insurance Form

Homeowner's checklist
What brings you here today?

I’m closing on a new homeI’m thinking of switchingI'm being non-renewedOther
Let’s start with your name.

First NameLast Name
Phone Number
Email
example@example.com
Date of birth

MonthDayYear
DOB
Your SSN: (For Farm/Ranch)
Do you have a second named insured?

YESNO
Second Named insured.

First NameLast Name
Second Named Insured Date of birth

MonthDayYear
DOB
Second Named insured SSN: (For Farm/Ranch)
What’s your home address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this your primary residence?

YesNo
Do you rent or own?

RENTOWN
Do you have a mortgage or loan?

Yes - 1Yes - 2No
Year purchased or move in date.

MonthDayYear
Date
What type of property is it?

Detached HomeMobile/ ManufacturedTownhouseCondoCo-opMulti-unit
What type of building is it?

Single familyDuplexTriplex/Fourplex
Number of stories
Is there a basement?

YesNo
Is the basement finished?

YesNo
What is the square footage of your home?
Square Footage
Who lives in your home?

It’s just myselfWe’re a coupleCouple with childrenMy children and IOther
How would you describe the condition of the Exterior & Interior?

Needs workStandardHighSuperb
Type of construction
Type of siding
When was your house built?
How do you heat your home?

GasElectricOther
Do you have a swimming pool?

YesNo
Is it fenced?

YesNo
Is there a diving board or slide?

NoDiving BoardSlideBoth
Do you have a trampoline?

YesNo
Do you have a dog?

YesNo
What breed is/are the dog(s)?
Did your home undergo any substantial renovations? If so, when?
*Leave blank if no renovations or unknown
Please describe the type of work that was done.
Do you have any of the following?

Fire alarmBurglar alarm
Did you file any home or property claim within the past 5 years?

NopeOnly oneMore than one
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Please provide the following pictures or documents.

- At least 2 photos of home showing all sides.

- At least 2 photos of detached structures showing all sides.

- Photo of house number.(for CA FAIR Plan)

- Photos or files of current declaration pages.

- Photos of any other pertinent documents.
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Homeowner's checklist

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