Personal Insurance Questionnaire

Please take care in answering all of the following preliminary questions which are relevant to obtaining insurance, setting the terms and estimated premiums. Underwriting requests are fully confidential. Please answer all questions to the best of your ability. If you are not certain of an answer, please put not sure and we will be glad to follow up and confirm.
Required Fields*

Personal Information

Name of Policy Holder*

First Last

Social Security Number*

Date of Birth*

Driver's License Number*

State*

Occupation

Employer

Marital Information

Marital Status*

Single
Married
Divorced
Widow

Spouse Name

First Last

Spouse Social Security Number

Spouse Date of Birth

Spouse Driver's License Number

Contact Information

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Home Number

Cell Number

Work Number

Fax Number

Email*

If you would like for us correspond and communicate with anyone other than yourself, please provide your permission to do so, and the name and contact information of the person(s) you designate.

Name	Phone	Email	Relationship

Property Information

Would You Like Us to Quote Your Property/Homeowners

Yes

Primary Property Address

Street Address Address Line 2 City State ZIP Code

County

Total Acreage

Year of Purchase

How many feet to the nearest fire hydrant?

Miles to nearest Fire Dept.

Year Built

Name of Fire Dept.

In a flood zone?

Flood coverage requested?

Does the home have a fortified certificate?

Is wind mitigation present?

Yes
No

Examples of Wind Mitigation impact glass, shutters or pre-cut plywood on premises. Wind mitigation & the fortified certificate are not one in the same. Fortified certificates are issued by IBHS, typically on newer homes & newer roofs.

Type of Plumbing

Age of Plumbing (if known)

Type of Roof

Age of Roof

Shape of Roof

Hip - All sides slope downward towards the gutter or the walls
Gable - Usually a triangle or "A" frame. Often will have a gable wall or a gable end in the roof wall

Number of Stories

Sq. Ft. of Home

Type of Foundation

If basement, Walkout/Sunlight?

Percent Finished

Please enter a number from 0 to 100.

Under Construction/Renovation

(If applicable) Age of:

Plumbing

Electric

Type of Electric

Heating

Loss History

Include both HOME AND/OR APPLICANT

Date	Type	Amount Paid

Any Open Claims

Exterior Construction

% Frame/Hardyboard

% Brick/Rock Veneer

% Stucco

% Other

Fireplace

Type of Fireplace

Chimney

Used for Supplemental Heating

Do You Have a Garage or Carport?

Yes

Number of Car Garage/Carport

Type of Car Garage/Carport

Type of construction if Detached

Other Structures

Outdoor Special Features

Swimming Pool

Type of Swimming pool

Diving Board and/or Slide?

List any Special Features?

Fenced with minimum 4' fence with locked gate?

Pool House/Cabana?

If yes, please include in Other Structure or else notate if attached to the home

Do you own any animals?

If so, what kind?

If dogs, what breed?

Any bite history?

Any business conducted on the premise?

What kind & how many employees?

Is Home Ever Rented to Others?

Is Tenant Required to Have Tenant Insurance Including Personal Liability Protection

Protection

Active Reporting Burglar Alarm

Active Central Reporting Fire Alarm

Alarm System Payment Schedule

Is your alarm service paid?

Central Reporting Burglar Alarm

Low Temperature Monitoring System

Permanently Installed Generator

Gas Leak Detector

24 Hour Signal Continuity

Sprinkler System with Waterflow

Gated Community

Does It Have a Human Guard?

Residential Sprinkler System

Water Leak Detection System

If yes, with alarm or without?

External Perimeter Gate

Full Time Live in Caretaker

Lightning Protection System

Perimeter Security Protection

If yes, what type?

Comments

Are There Any Other Properties That Need to be Quoted?

Yes

Other Property Information

Primary Property Address

Street Address Address Line 2 City State ZIP Code

County

Total Acreage

Year of Purchase

How many feet to the nearest fire hydrant?

Name of Fire Dept.

Miles to nearest Fire Dept.

In a flood zone?

Flood coverage requested?

Does the home have a fortified certificate?

Is wind mitigation is present?

Yes
No

Examples of Wind Mitigation impact glass, shutters or pre-cut plywood on premises. Wind mitigation & the fortified certificate are not one in the same. Fortified certificates are issued by IBHS, typically on newer homes & newer roofs.

Year Built

Age of Plumbing (if known)

Type of Plumbing

Age of Roof

Type of Roof

Shape of Roof

Hip - All sides slope downward towards the gutter or the walls
Gable - Usually a triangle or "A" frame. Often will have a gable wall or a gable end in the roof wall

Number of Stories

Sq. Ft. of Home

Type of Foundation

If basement, Walkout/Sunlight?

Percent Finished

Please enter a number from 0 to 100.

Under Construction/Renovation

(If applicable) Age of:

Plumbing

Electric

Type of Electric

Heating

Loss History

Include both HOME AND/OR APPLICANT

Date	Type	Amount Paid

Any Open Claims

Exterior Construction

% Frame/Hardyboard

% Brick/Rock Veneer

% Stucco

% Other

Fireplace

Type of Fireplace

Chimney

Used for Supplemental Heating

Do You Have a Garage or Carport?

Yes

Number of Car Garage/Carport

Type of Car Garage/Carport

Type of construction if Detached

Other Structures

Outdoor Special Features

Swimming Pool

Type of Swimming pool

Diving Board and/or Slide?

List any Special Features?

Fenced with minimum 4' fence with locked gate?

Pool House/Cabana?

If yes, please include in Other Structure or else notate if attached to the home

Do you own any animals?

If so, what kind?

If dogs, what breed?

Any bite history?

Any business conducted on the premise?

What kind & how many employees?

Is Home Ever Rented to Others?

Is Tenant Required to Have Tenant Insurance Including Personal Liability Protection

Protection

Active Reporting Burglar Alarm

Active Central Reporting Fire Alarm

Alarm System Payment Schedule

Is your alarm service paid?

Central Reporting Burglar Alarm

Low Temperature Monitoring System

Permanently Installed Generator

Gas Leak Detector

24 Hour Signal Continuity

Sprinkler System with Waterflow

Gated Community

Does It Have a Human Guard?

Residential Sprinkler System

Water Leak Detection System

If yes, with alarm or without?

External Perimeter Gate

Full Time Live in Caretaker

Lightning Protection System

Perimeter Security Protection

If yes, what type?

Comments

Auto Information

Would You Like Us to Quote Your Auto?

Yes

Current Limits of liability protection:

List all residents with a valid driver's license including students away at school with or without a vehicle

Name	DOB	Driver's License # & state	Occupation

List all vehicles

Year	Make/Model	VIN	Value	Vehicle Recovery Device i.e. ON STAR	Usage	Principal Operator	Name on Title	Purchased New or Used	Length of ownership

Are any of the vehicles financed?

Any claims in the household in the last 5 years?

This includes towing, windshield, tickets, violations and/or accidents

If so, please list a brief description of occurrence below

Any other claims?

Comments

General Information

Any other Legal Entities?

Prior/Current Insurance Provider

Expiration/Renewal Date

Have you ever had an Insurance policy cancelled or not renewed?

Reason for cancellation

Comments

May We Also Quote:

Umbrella

Personal Articles

Life

Toys

Collector Auto

Please attach current policies or any helpful documents

Drop files here or

Accepted file types: pdf, jpeg, jpg, png, Max. file size: 50 MB.

Once submitted, a copy will be sent to your designated emails with the social security number and driver’s license number omitted.

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