NJAN Homeowners Questionnaire
Effective Date
*
-
Month
-
Day
Year
Date
First Named Insured
Name of Insured
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Occupation
*
ex. Business Name
Marital Status
*
Divorced
Married
Separated
Single
Widowed
Additional Insured
Name of Insured
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Occupation
*
ex. Business Name
Marital Status
*
Divorced
Married
Separated
Single
Widowed
Demographic Information
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Property Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Indicate if new purchase
*
Yes
No
If new purchase, indicate closing date
-
Month
-
Day
Year
Prior Address (if less than 4 years at current address)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Residence Type
*
Home
Condo
Townhouse (HO3)
Townhouse (HO6)
Apartment
Renter
Usage
*
Primary
Secondary
Occupancy
*
Owner
Tenant
Is the home in foreclosure?
*
Yes
No
Is the home vacant?
*
Yes
No
Is the current policy being Non-Renewed?
*
Yes
No
Current Insurance Company
*
Expiration date of current policy
*
-
Month
-
Day
Year
Current premium
*
Number of years with current insurance company
*
If no prior coverage, please explain:
Mortgagee Information
*
Payor
*
Insured
Mortgagee
Dwelling Amount
*
Liability Amount
*
Deductible Amount
*
Home Information
Style of Home
*
Cape Cod
Colonial
Ranch
Rowhome
Split Level
Townhome
Other
Number of families
*
Number of stories
*
Number of rooms
*
Number of bathrooms
*
Year built
*
Total Square Footage
*
Roof update year
*
Roof Update Type
*
Complete
Partial
Roof Condition
*
Partial
Fair
Good
Excellent
Roof Type
*
Pitched
Flat
Roof Material
*
Asphalt Shingle
Composition
Rubber
Stone
Wood
Metal
Other
Plumbing update year
*
Plumbing Update Type
*
Complete
Partial
Plumbing Material
*
PVC
Copper
Other
Wiring update year
*
Wiring Update Type
*
Complete
Partial
Wiring Material
*
Circuit Breaker
Fuses
Knob and tube
Heating update year
*
Type of heat
*
Gas
Oil
Electric
Wood burning stove
Secondary heating system
*
Yes
No
Oil tank location
*
Was there ever an oil tank on the property?
*
Yes
No
Construction type
*
Frame
Masonry
Other
Exterior Walls
*
Vinyl Siding
Brick
Stucco
EIFS
Aluminum
Other
If other, please specify
Foundation
*
Slab
Crawl Space
Basement (finished)
Basement (unfinished)
Garage
*
Yes
No
Garage type
*
Attached
Built-In
Detached
None
Number of doors in garage
*
Distance (in feet) to any neighboring structure
*
Pool
*
Yes (above-ground)
Yes (in-ground)
Yes (indoor)
No
Diving Board
*
Yes
No
Slide
*
Yes
No
Trampoline
*
Yes (with netting)
Yes (no netting)
No
Dog(s)
*
Yes
No
Type of breed(s)
*
Bite History
*
Yes
No
Type of animal(s)
*
Other type of animals
*
Yes
No
Credits/Discounts
Smoke alarm
*
Local (smoke detector)
Central
Direct
None
Burglar alarm
*
Local
Central
Direct
None
Deadbolt locks
*
Yes
No
Fire alarm
*
Local
Central
Direct
None
Temperature monitoring
*
Local
Central
Direct
None
Gas leak detection
*
Local
Central
Direct
None
Gated community
*
Yes
No
Mature homeowner (55+)
*
Yes
No
Automatic water shut-off
*
Yes
No
Whole house generator
*
Yes
No
Sprinkler system
*
Yes
No
Additional Information
Has the Insured or Risk had any loses in the past 5 years?
*
Yes
No
If yes, please describe:
Has any coverage been declined, canceled or non-renewed during the last five (5) years?
*
Yes
No
Has any applicant or driver had a foreclosure, repossession, Bankruptcy, Judgement or lien during the last five (5) years?
*
Yes
No
Is the risk currently under construction?
*
Yes
No
Does the applicant own any recreational vehicles (snow mobiles, dune buggies, mini bikes, ATVs, etc.) not scheduled on this policy?
*
Yes
No
Any business conducted on premesis?
*
Yes
No
Is the dwelling/home for sale?
*
Yes
No
Are solar panels present?
*
Yes
No
If so, how much of the roof is covered?
Is the property within 300 feet of commercial or non-residential property?
*
Yes
No
If yes, describe in detail:
Submit
Should be Empty: