Home Owners Insurance

All Fields in Yellow are Required.

HOMEOWNERS QUESTIONNAIRE

Name Insured:
Co-Applicant:
Property Address:
City:
State:
Zip:
Mailing Address:
City:
State:
Zip:
Home:
Cell:
Work:
Fax:
Email:

EMPLOYMENT AND PERSONAL INFORMATION

Occupation:
Employer:
Date of Birth:
Co-Applicant's Occupation:
Employer:
Date of Birth:

UNDERWRITING INFORMATION

Prior Company:
Prior Policy #:
Expiration Date:
What year was the home built?
Home Construction Type: Masonry Frame
Total Living Area:
Is the Property Rented? Yes No
How Many Years Have You Lived at this Property Address?
Type of Home: Single Family Condo Townhome Other
Number of Stories:
Number of Families:
Number of Units in Bldg:
# of Bedrooms:
# of Full Baths:
# of Half Baths:
Fireplace: Yes No
Garage: None Attached Unattached
# of Car Garage:
Do You Have Hurricane Shutters? Yes No (If Yes, Please Provide Documentation)
Central Station Monitored Alarm:
Fire Yes No
Burglar Yes No
Swimming Pool: Yes No
Do You Have a Diving Board or Slide? Yes No
Screen Porch Size:
Balcony Size:
Wood Deck:
Is Your Home Located in a Gated Community? Yes No
Is there Manned Security? Yes No
Do You Have Flood Insurance? Yes No
If Yes, Carrier:
Exp. Date:

COVERAGES

A. Dwelling $ (Rebuild home, not including land)
B. Other Structures $ (2% or 10% unattached: (pool, screen enclosure, fence, etc))
C. Personal Property $ (50% contents: (furniture, clothing, etc))
D. Loss of Use $ (Amount to live elsewhere while repairing damage)
E. Personal Liability $
F. Medical Payments $

CLAIM HISTORY

Any Prior Claims: Yes No
If Yes, Date of Loss:
Type of Claim:
Claim Description:
Amount Paid:
Company That Paid Claim:
2^nd Claim if Applicable
Date of Loss:
Type of Claim:
Claim Description:
Amount Paid:
Company That Paid Claim:

IMPORTANT AUTO & LIFE INFORMATION

Who Do You Currently Have Your Auto Insurance With?
What Is The Expiration Date:
What Are Your BI Limits:
Who Do You Currently Have Your Mortgage Protection With:
How Did You Hear About Us?