Homeowners Insurance Questionnaire
Applicant's Information
Name
Social Security #
Address
City
State
Zip
Date of Birth
Home Phone
Work Phone
Years at this address
Previous Address
City
State
Zip
Occupation
Co-Applicant Name
Social Security #
Date of Birth
Home Phone
Work Phone
Currently employed?
Yes
No
Occupation
Are you currently insured?
Yes
No
Current Insurance Company
How long with last insurance company?
Insurance ever been cancelled, declined or non-renewed?
Dwelling replacement cost
Year Built
Square Feet
# of stories
Feet to fire hydrant
Miles to fire department
Type of Heating
Dwelling Construction Type
Exterior Wall Covering
Foundation Type
Slab
Crawl Space
other
Roof Type
Last update when?
Slope of terrain
Level
Slight slope
Moderate slope
Steep slope
Cut pad (in a hill side)
Garage type
Attached
Detached
Built-in
No Garage
Number of parking spaces
Number of fireplaces
What type
Masonry
Prefabricated
Insert
Other:
# of bathrooms
Plumbing last updated
Does the property have
Yes
No
Give Details
A basement
Full
or Partial
Burglar alarm
Fire sprinkler system
Any guard (type) dogs or dogs with a bite history
Any horses
A home-based business
(type)
Auxiliary heating
(type)
Swimming pool
Hot tub/Jacuzzi
Air conditioning
Sauna
Heat pump
Central vacuum
A deck
sq. ft.
A porch
sq. ft.
A breezeway
Scheduled Personal Property
Jewelry ($)
Furs ($)
Fine Art ($)
Silver ($)
Cameras ($)
Other ($)
Have you had any previous claims?
Yes
No
When?
Amount / Explanation