Personal Insurance Questionnaire
KASTENDIKE INSURANCE GROUP
Name Insured (1): DOB:Occupation/Employer: SS#
Name Insured (2): DOB:Occupation/Employer SS#
Contact Phone Number:Email Address:Effective Date of Coverage
Address of Property to be insured:
COUNTY
YEAR BUILT
SQUARE FOOTAGE OF HOME
Occupancy:
PRIMARY RESIDENCE
BUILDER RISK
RENTED
VACATION HOME
CONSTRUCTION
BRICK
WOOD SIDING
STONE
STUCCO
FRAME
MASONARY
ROOF TYPE AGE
Shingle
METAL
SLATE
TAR
TIN
Does the home haveprofessionally installed solarpanels?
YES
NO
NUMBER OF STORIES
DOES HOME HAVE A BASEMENT
YES
NO
% BASEMENT FINISHED
25
50
75
100
Description of OtherStructures: (Pools, Gazebos,Walkways etc.)
(California Only) Has thehome been retrofitted forearthquakes? If so, whatyear?
Is the home located in a floodzone? If so, is there a currentflood policy?
YES
NO
Has the electric, plumbingand heating been updated?
YES
NO
ELECTRIC WHAT YEAR DESCRIBE
HEATING WHAT YEAR DESCRIBE
PLUMBING WHAT YEAR DESCRIBE
Does the home have anyother loss preventiondevices?
Back-up Generator
Water Leak Detection
Water Leak Detection
Gated Home
Lightning Protection
Do you own a dog?Is there a bite history?
NO DOG
YES DOG
BITE HISTORY YES
BITE HISTORY NO
Number of miles to closestFire Dept?Number of feet to closest firehydrant?
Building Coverage Requested
Contents Coverage Requested
Deductible Requested:
Wind/Hail Deductible:
Current Insurance Carrier:
Have there been any paidclaims for the past 36months?
YES
NO
Details of Claim Activity:(Date, Amount Paid,Description of damage andwhat occurred)
Have you been or are youcurrently being cancelled,declined or non-renewed?
YES
NO
If Yes, please explain
Choose any that areapplicable:
FINE ARTS
SILVER
JEWELRY
WINE
Miscellaneous
Specific Collections Details:
Umbrella Limit Requested:
AUTO INFORMATION
PRIMARY DRIVER SECONDARYDRIVER DRIVER 3 DRIVER 4
Rows
NAME
NAME
NAME
NAME?
State and Driver’s
License #:
Date of Birth:
Education:
Employment:
Marital Status:
Annual Miles Driven:
Miles One Way to
Work/School
Defensive Driving
Course (Date):
Claims/Violation
History (Date and
Description):
VEHICLES
Rows
VEH1
VEH2
VEH3
VEH4?
VEH5
VEH6
MAKE
YEAR
MODEL
VIN#
Lienholder
on vehicle:
Prior Insurance Carrier/Expiration
Date:
Limits of Prior Coverage/Deductible
How long have you been insured
with your current carrier?
Preferred Billing Option (select one):
MONTHLY
Quarterly
Semi-Annually
Annually
Home Premium Escrowed
YES
NO
Mortgagee Clause:
Submit
Should be Empty: