Homeowner Insurance Questionnaire
High Value
Name
*
First Name
Last Name
Property Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Is this also the mailing address?
*
Please Select
Yes
No
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
*
Social Security Number
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Do you have a spouse and/or co-applicant?
*
Please Select
Yes
No
Spouse/Co-Applicant Name
*
First Name
Last Name
Spouse/Co-Applicant Occupation
*
Relation to Insured
*
Spouse/Co-Applicant Date of Birth
*
-
Month
-
Day
Year
Date
Spouse/Co-Applicant Social Security Number
*
Effective Date/Expected Closing Date
*
-
Month
-
Day
Year
Date
Does the property have a mortgage?
*
Please Select
Yes
No
Occupancy
*
Please Select
Primary
Secondary
Rental
Building Year Built
*
Square footage of living space
*
Number of stories
*
Construction (Brick, siding, stucco, other -- please specify)
*
Has home been renovated? Indicate year done and extent of renovation
*
Year roof replaced
*
Roof material (shingle, slate, metal, tile)
*
Does the roof have hurricane straps or clips?
*
Please Select
No
Yes, Straps
Yes, Clips
Yes, Unknown
Year electrical updated
*
Year plumbing updated
*
Year heating/air updated
*
Is there a pool?
*
Please Select
Yes
No
Monitored burglar alarm?
*
Please Select
Yes
No
Monitored fire alarm?
*
Please Select
Yes
No
Is this building in a gated community?
*
Please Select
Yes
No
If yes, are the gates guarded?
*
Please Select
Yes
No
Are there hurricane shutters?
*
Please Select
Yes
No
Is there a backup generator?
*
Please Select
Yes
No
Impact-resistant glass?
*
Please Select
Yes
No
Do you have a dog?
*
Please Select
Yes
No
Do you have items that need to be scheduled (furs, jewelry, silver, fine arts, etc.) ?
*
Please Select
Yes
No
Is this house sprinklered?
*
Please Select
Yes
No
If yes, is there a Water Flow Alarm?
*
Please Select
Yes
No
N/A
Do you have security cameras on your property that are monitored?
*
Please Select
Yes
No
Do you have a gas leak detector?
*
Please Select
Yes
No
Is there a Lightning Protection System?
*
Please Select
Yes
No
Is there a Water Leak Detection System with Master Shut Off?
*
Please Select
Yes
No
Submit
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