Home and Auto Questionnaire

1
Applicant Information
Applicants First Name
Applicants Last Name
Please Select
Please Select
Male
Female
Sex
Date of birth
Please Select
Please Select
Single
Married
Divorced
Widowed
Marriage Status
Zipcode
Industry
Occupation
2
Applicant information
Driver’s License Number
Please Select
Please Select
High school Diploma
Associates Degree
Bachelor’s Degree
PhD
Masters
Highest Education Level
Please enter your email
Please enter phone number
3
Primary Address
Street Address
Street Address Line 2
City
State
Zipcode
Please Select
Please Select
Home
Condo
Renters
Adress Type
If Condo or Renters: UNIT #
Please Select
Please Select
0-3
4-6
7+
Years at address
4
Previous AddressPlease fill in if you have not lived at current address for at least 3 years
Street Address
Street Address Line 2
City
State
Zipcode
Years at address
5
Spouse InformationType N for industry & occupation if no spouse
Co-Applicants First Name
Co-Applicants Last Name
Please Select
Please Select
Male
Female
Sex
Date of birth
Please Select
Please Select
Single
Married
Divorced
Widowed
Marriage Status
Industry
Occupation
6
Spouse information
Driver’s License Number
Please Select
Please Select
High school Diploma
Associates Degree
Bachelor’s Degree
PhD
Masters
Highest Education Level
Please enter your email
Please enter phone number
7
Prior Carrier information
Prior Insurance Carrier
Prior policy expiration
Please Select
Please Select
State Minimum
50/100
100/300
250/500
500/500
Prior Liability Limits
Premium Total
Years with prior carrier
8
Vehicle 1
Vin Number
Please Select
Please Select
Pleasure
To/From work
Business
Vehicle use
Date Purchased (Month/year)
Please Select
Please Select
Owned
Lease
Lien
Ownership type
Estimated annual miles
9
Vehicle 2
Vin Number
Please Select
Please Select
Pleasure
To/From work
Business
Vehicle use
Date Purchased (Month/year)
Please Select
Please Select
Owned
Lease
Lien
Ownership type
Estimated annual miles
10
Vehicle 3
Vin Number
Please Select
Please Select
Pleasure
To/From work
Business
Vehicle use
Date Purchased (Month/year)
Please Select
Please Select
Owned
Lease
Lien
Ownership type
Estimated annual miles
11
Vehicle 4
Vin Number
Please Select
Please Select
Pleasure
To/From work
Business
Vehicle use
Date Purchased (Month/year)
Please Select
Please Select
Owned
Lease
Lien
Ownership type
Estimated annual miles
12
Additional Driver 1
First Name
Last Name
Drivers License Number
Date of Birth
Please Select
Please Select
Yes
No
Student
Please Select
Please Select
Included on policy
Excluded on policy
Driver Inclusion/Exclusion
13
Additional Driver 2
First Name
Last Name
Drivers License Number
Date of Birth
Please Select
Please Select
Yes
No
Student
Please Select
Please Select
Included on policy
Excluded on policy
Driver Inclusion/Exclusion
14
Additional Driver 3
First Name
Last Name
Drivers License Number
Date of Birth
Please Select
Please Select
Yes
No
Student
Please Select
Please Select
Included on policy
Excluded on policy
Driver Inclusion/Exclusion
15
Additional Driver 4
First Name
Last Name
Drivers License Number
Date of Birth
Please Select
Please Select
Yes
No
Student
Please Select
Please Select
Included on policy
Excluded on policy
Driver Inclusion/Exclusion
16
Prior CarrierPlease only fill out if it was a different Carrier than your Auto policy
Carrier Name
Policy Expiration Date
1 to 2
3 to 4
5+
Years with prior carrier
17
Home InformationCentral - systems alert both homeowners and the proper authorities in the case of true emergencies. Direct - Has direct communication with a monitoring center or emergency services. Local - These systems sound an alarm to alert home and business owners of emergencies. However, these systems do not contact authorities.
Please Select
Please Select
Local
Central
Direct
None
Fire detection
Please Select
Please Select
Partial
Full
None
Sprinkler System
Please Select
Please Select
Local
Central
Direct
None
Burglar Alarm
18
Scheduled ItemsJewelry, Furs, Silver, Guns, Business equipment, Computers, Fine Arts, Collectibles/Collections. Blanket Coverage only coverages items below $50,000. Scheduled Coverage is for any single item over $50,000 (Must have appraisal for each item!)
Please Select
Please Select
Yes
No
Blanket Coverage
Please Select
Please Select
Yes
No
Scheduled Coverage
19
Is there anything else you would like to add?Thank you for filling out this form, not only does it make the process easier and more efficient! Please Email all declarations pages to thomas@pswplanning.com
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20
Please add all declarations pages here Or Email them to thomas@pswplanning.com
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