Homeowners Insurance Application

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: 651-291-1119

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Homeowners Questionnaire

Usage (optional)

First Named Insured (optional)

DOB (optional)

Occupation/Education (optional)

Second Named Insured (optional)

DOB (optional)

Relationship (optional)

Occupation/Education (optional)

Cell Phone (optional)

Work Phone (optional)

Home Phone (optional)

Email Address (optional)

Current Address (Street, City, State, Zip Code, County) (optional)

Location Address (Street, City, State, Zip Code, County) (optional)

Mailing Address (Street, City, State, Zip Code, County) (optional)

Current Insurance Co. (optional)

Current Coverage on Dwelling (optional)

Current Deductible (optional)

Year Built (optional)

Purchase Price (optional)

Roof Type (Asphalt, Shake, Tile, Flat, Rubber, Other) (optional)

Const. Type (Frame, Brick, Brick Veneer) (optional)

Siding Type (optional)

Is there any Stucco? (optional)

House Type (1 story, 1 1/2 story, 2 story, 2 1/2 story, bi-level, split level) (optional)

Finished sq. footage (excluding basement) (optional)

Baths (# of Full, # of 1/2, # of 3/4) (optional)

Flooring (% Wood, % Carpet, % Tile, % Vinyl) (optional)

Garage (Attached, Detached, Tuck Under, None) (optional)

Garage (# of Cars) (optional)

Deck sq. footage (optional)

Porch (Open or Closed) (optional)

Porch sq. footage (optional)

Basement (Slab, Crawl, Etc.) (optional)

Basement finished sq. footage (optional)

Basement Walkout (Yes or No) (optional)

Central Air (Yes or No) (optional)

Year of Updates (Roof, Plumbing, Heating, Electric) (optional)

Do you currently have a personal umbrella policy? (Y/N, Limit, UM) (optional)

Any losses in the last 5 years? (optional)

Deductible Options to quote ($1,000, $1,500, $2,500, $5,000, $10,000) (optional)

Misc.

Hot Tub (optional)

Sauna (optional)

Trampoline (optional)

Other Structures (optional)

Sump Pump (optional)

Const. Category (Builders Grade, Semi-Custom, Custom, Designer) (optional)

Central Alarm (optional)

Burglar Alarm (optional)

Fire Alarm (optional)

Miles to the Fire Dept. (optional)

Responding Fire Dept. name (optional)

Feet from fire hydrant (optional)

Wood burning stove (optional)

Fireplaces (How many? Gas or Wood?) (optional)

Pets (Type, Breed) (optional)

Swimming Pool

Do you have a swimming pool? (optional)

In ground? (optional)

Above ground? (optional)

Diving board? (optional)

Depth under diving board (optional)

Slide? (optional)

Fully fenced? (optional)

Inland Marine

Jewelry (optional)

Furs (optional)

Fine Arts (optional)

Collectibles (optional)

Silverware (optional)

Guns (optional)

Musical Instruments (optional)