Schumacher Insurance: Portfolio Questionnaire

1
Full Name* This field is required.
First Name
Last Name
2
Date Of Birth* This field is required.
Date
Month
Day
Year
3
What is your occupation?* This field is required.
4
If married, what is the full name of your spouse/partner?
5
Date Of Birth - Spouse/Partner
Date
Month
Day
Year
6
What is your spouse/partners occupation?* This field is required.
7
What is your home address (or the address of the home you are purchasing?)* This field is required.
8
What is your current address (If purchasing a new home). Please put "None" if not applicable.* This field is required.
9
If the home is a new purchase, do you plan on doing any renovations? Please put "None" if not applicable.* This field is required.
10
Best Email Address* This field is required.
example@example.com
11
Best Phone Number* This field is required.
Please enter a valid phone number.
12
What date are you looking for coverage to become effective?* This field is required.
Date
Month
Day
Year
13
How did you hear about?* This field is required.
14
What year was your home built? * This field is required.
15
How many bathrooms are in your home?* This field is required.
16
How long ago was your roof last updated?* This field is required.
0-5 years
5-10 years
10-15 years
15-20 years
21+ years
17
What type of roof do you have?* This field is required.
18
What year was the electric last updated?* This field is required.
19
What year was the plumbing last updated?* This field is required.
20
What year was the heating system last updated?* This field is required.
21
What type of heating do you have in your home?* This field is required.
Gas
Electric
Oil
22
If oil heat, where is your oil tank located?* This field is required.
Outside on a concrete slab
Basement
Underground
23
Foundation of your home* This field is required.
Crawl Space
Slab
Unfinished Basement
Finished Basement
Partially Finished Basement
24
Do you have sump pumps in your basement?* This field is required.
YESNO
25
Do you have central station burglar/fire alarms in your home?* This field is required.
Burglar
Fire
Both
None
26
Do you have a whole house, professionally installed generator, such as Generac?* This field is required.
YESNO
27
Do you have water sensors or an automatic water shut off in the home?* This field is required.
YESNO
28
Do you have a pool at your home?* This field is required.
YESNO
29
Does your pool have a diving board?* This field is required.
YESNO
30
Does your pool have a slide?* This field is required.
YESNO
31
Do you have a trampoline at your home?* This field is required.
YESNO
32
Does your trampoline have a safety net?* This field is required.
YESNO
33
Does your family have a dog in the home?* This field is required.
YESNO
34
What is the breed of your dog? If 'mixed' or 'mutt' please specify ALL breeds of your dog.* This field is required.
35
Would you like a separate flood insurance quote? (Flood is not covered by your homeowners carrier)* This field is required.
YESNO
36
How many homeowners claim have you had in the past 5 years?* This field is required.
0
1
2
3+
37
Who is your current Homeowner Carrier?* This field is required.
38
Are you being cancelled or non-renewed by your current homeowners carrier?* This field is required.
YESNO
39
Who is your current Auto Carrier?* This field is required.
40
How many total vehicles do you own, finance, or lease?* This field is required.
1 Vehicle
2 Vehicles
3 Vehicles
4. Vehicles
5 Vehicles
More than 5 vehicles
41
How many total licensed driver(s) live in your home OR have regular use of your vehicles?* This field is required.
1 - Licensed Driver
2 - Licensed Drivers
3 - Licensed Drivers
4 - Licensed Drivers
5 - Licensed Drivers
More than 5 licensed drivers
42
Please provide the names, dates of birth, and driver's license numbers of all household members.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
43
Please provide all vehicles' year, make & model and/or VIN#* This field is required.
Huge
Large
Normal
Small
Ok
Ok
44
Garaging Zip Code* This field is required.
45
Have any drivers in your household had any tickets or accidents in the last 5 years?* This field is required.
YESNO
46
How do you prefer to pay for your auto policy?* This field is required.
Monthly out of the checking account
Pay in full (for an additional discount)
47
Does anyone in your household drive for Uber/Lyft/Door Dash or any delivery service?* This field is required.
YESNO
48
Are you being cancelled or non-renewed by your current auto carrier?* This field is required.
YESNO
49
Do you have AAA?* This field is required.
YESNO
50
Do you currently have an umbrella policy in place?* This field is required.
YESNO
51
Would you like us to look into an umbrella policy for you?* This field is required.
Yes
No
52
Do you have any of the following you would like to insure?* This field is required.
Jewelry
Fine Arts/Antiques
Guns
Memorabilia
None of the above
53
Do you have any of the following you would like to insure?* This field is required.
Boat/Yacht
Jetski
Motorcycle
Golf Cart/ATV/Dirt Bike
Rental/Investment Property
Second Home
Commercial Real Estate (Apartment Building, Strip Mall, etc.)
Life Insurance/ Long Term Care/ Disability
None of the above
Should be Empty: