Home Insurance Questionnaire

If you would like to receive a quote for your Personal Home Insurance, simply fill out the form below and submit. Our helpful agent will contact you for your social security number and we will prepare your quote promptly.

Personal Lines Home Questionnaire
First Name	Middle Initial	Last Name		DOB
Co-Applicant First Name	Middle Initial	Last Name		DOB
Address
City	State	Zip Code	County
Phone No.	Ext.	Email
Present Carrier	Exp. Date	Group Name, Group # Member #
Property Location (If different)		County
Feet to Hydrant	Miles to Fire Station	Township If not in city limits

Form: HO3 Renters (HO4) Condo (HO6) Rental Dwelling Seasonal

Current Limits		Non-Smokers?	Yes	No
Coverage A		Alarm System?	Yes	No
Coverage B		If yes to Alarm Local Police Central
Coverage C		Smoke Dectectors?	Yes	No
Coverage D		Fire Extinguisher?	Yes	No
Coverage E		Dead Bolt Locks? (on every exterior door)	Yes	No
Coverage F		Sump Pump?	Yes	No
Deductible		Wood Stove?	Yes	No
Current Market Value		Swimming Pool?	Yes	No
If Rental Property		Above Ground?	Yes	No
Is home occupied? Yes No		Swimming Pool Fence ?	Yes	No
If not, when?		Pool Fence Locked?	Yes	No
Monthly Rent?		Swimming Pool Fence Height
Value of Landlord's Contents $		Diving Board?	Yes	No
Note: photos are required to bind coverage		Home Business?	Yes	No
		Watercraft?	Yes	No
What Year Were the Following Systems Updated?		Trampoline?	Yes	No
Plumbing		Hot Tub?	Yes	No
Electrical		Hot Tub Locked Cover?	Yes	No
Heating		Dogs?	Yes	No
Air Condition		How Many Dogs?
Roof		Breed(s)
Any Claims in the last 5 Years Yes (complete below) No
Date Type Paid $
Date Type Paid $
Date Type Paid $
Schedule of Personal Property
Jewelry: # of items Total Value $
Furs: # of items Total Value $
Fine Arts: # of items Total Value $
Replacement Cost Information
Year Built:		No. of Families 1 2 3 4
Number of Stories : 1 1.5 2 3 Tri-Level Bi-Level
Exterior Wall Material: Frame % Masonry Veneer % Masonry %
Square Footage: 1st Level 2nd Level 3rd Level
Basement: sq feet Crawl Space Slab Walkout
Yes No	Garage: Attached Detached 1 car 2 car 3 car 4 car Built In Basement Carport
Yes No	Finished Attic: sq. feet
Yes No	Air conditioning: Using heating ducts Seperate Ducts
Yes No	Attached Three-Wall Room Addition: Sq. Feet 1 Story 1.5 Story 2 Story Masonry/Brick Veneer Frame With Basement Without Basement 1 Story Over Garage Stories over Garage
Yes No	Breezeway: Square Feet Open Wall Enclosed Wall
Yes No	Porch: Square Feet 1 Story 1 Story with sundeck 2 Story Open Wall Enclosed Wall
Yes No	Decks or Balconies: Square Feet
Yes No	Fireplace: Number of Chimneys Number of Hearths
Yes No	Baths: Total Number of Full Baths Total Number of Half Baths
Yes No	Screened Aluminum Enclosure: sq feet On Posts Slab Foundation Wall

Built-Ins: Please check all that apply
Skylight	Jacuzzi/Jet Tub	Water Softener	Counter-Top Range	Sauna
Intercom	Central Stereo System	Central Vacuum	Double Oven	Oven
Wet Bar	Prefab Fireplace Insert	Ceiling Fan	Other please specify

Floor Coverings: Carpet % Hardwood % Tile % Linoleum % Parquett% Pergo %
Window Types: Oversized Picture Windows # Sliding Glass Doors # Arched # French Doors #(Interior/Exterior) Bay # Bows # Stained Glass# Garden#
Notes to Agent (Please give details regarding Home Business or Watercraft, etc)