Page Insurance, Ltd
102 Boston Street
Guilford, CT 06437
(203) 453-5258
info@pageins.com
Client Information and Address
Name Insured
*
First Name
Last Name
Marital Status
Single
Married
Divorced
Widowed
Date of Birth
Named Insured Occupation / Employer / Education Level
Occupation
Employer
Education Level
Name of Spouse
First Name
Last Name
Date of Birth
Spouse Occupation / Employer / Education Level
Occupation
Employer
Education Level
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Address of Insured Location (if different than mailing address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Is this a New or Renewal Policy?
*
New
Renewal
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Property Information
Type Occupancy
*
Owner Occupied Home
Tenant Occupied Home
Owner Occupied Condo
Tenant Occupied Condo
If tenant occupied, do you rent on a short term basis (AirBnB, Home Away or similar)?
Yes
No
Wiring
*
Original
Fully Updated
Partially Update
Year Updated
*
Enter Year
Notes
Plumbing
*
Original
Fully Updated
Partially Update
Year Updated
*
Enter Year
Notes
Heating
*
Original
Fully Updated
Partially Update
Year Updated
*
Enter Year
What year was the furnace last replaced?
*
Notes
Roofing
*
Original
Fully Updated
Partially Update
Year Updated
*
Enter Year
Type of Roof Material
Asphalt (typical)
Wood Shakes
Slate
Notes
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Select 'Yes' or 'No' to the questions below:
Is the property vacant or unoccupied?
*
Yes
No
Notes
Is dwelling under construction or renovation?
*
Yes
No
Is the property isolated?
*
Yes
No
Are there any adjacent dwellings within 20 ft. of the risk?
*
Yes
No
If yes, enter exact measurement
Any child care or other business conducted on premises?
*
Yes
No
If yes, indicate # of children
Is the property occupied by undergraduate students?
*
Yes
No
Any dogs or other animals on premises?
*
Yes
No
If yes, indicate breeds and explain any biting incidents
Is the electrical service less than 100 Amps?
*
Yes
No
Are Edison-based fuses or knob-and-tube wiring in use?
*
Yes
No
Is there a wood stove or coal stove on premises?
*
Yes
No
Professionally installed ?
Yes
No
Is the home listed on the National Historic Registry
Yes
No
Is the home heated with oil?
*
Yes
No
Where is tank located?
When was it last cleaned?
Is there a pool on premises?
*
Yes
No
Type and any additional info
Any trampolines on premises?
*
Yes
No
Does it have net
Yes
No
Any outbuildings?
*
Yes
No
If yes, describe use and occupancy
Any insurance declined, cancelled or non renewed in last 3 years?
*
Yes
No
Notes
Has applicant been convicted of any degree of arson in last 10 years?
*
Yes
No
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Additional Information
Add any notes or anything else you want to communicate here:
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