Homeowner Insurance Questionnaire
Name
First Name
Last Name
Business 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
*
Current Insurance Company
Expiration Date/Expected Closing Date
*
-
Month
-
Day
Year
Date
Current/Requested Building Limit
*
Occupancy
*
Please Select
Primary
Secondary
Rented to others
If rented to others, Short or Long term rental?
*
Please Select
N/A
Short Term Rental
Long Term Rental
How many units
*
Building Year Built
*
Square footage of living space
*
Number of stories
*
Construction Type (Brick, siding, stucco, other -- please specify)
*
Has home been renovated? Indicate year done and extent of renovation
*
Foundation Type
*
Please Select
Slab
Raised
Year roof replaced
*
Shape of roof
*
Please Select
Hip
Gable
Unknown
Roof Material
*
Please Select
Asphalt Shingle
Slate
Metal
Other
Year electrical updated
*
Year plumbing updated
*
Year heating/air updated
*
Location of water heater (outside, first floor, above first floor)
*
Age of water heater
*
Please Select
0-5 Years
5-10 Years
10 Years or Older
Is there a pool?
*
Please Select
Yes
No
If yes, is pool fenced?
*
Please Select
Yes
No
Does pool have diving board or slide?
Please Select
Diving Board
Slide
None of the above
Is there a trampoline?
*
Please Select
Yes
No
Monitored burglar alarm?
*
Please Select
Yes
No
Monitored fire alarm?
*
Please Select
Yes
No
Is there a monitored security camera system?
*
Please Select
Yes
No
Is this building in a gated community?
*
Please Select
Yes
No
Do you have a dog?
*
Please Select
Yes
No
Dog breed?
*
Is there a full house generator?
*
Please Select
Yes
No
Does the property have solar panels?
*
Please Select
Yes
No
Has there been any claims in the past 3 years?
*
Please Select
Yes
No
If yes, has the claim been finalized or closed?
*
Approximate amount of settlement payment
*
Submit
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