Homeowners Insurance Questionnaire

Please complete the following questionnaire to receive a quotation on your homeowners insurance.

Click here to go to our
Automobile Insurance Questionnaire

General Information (asterisk indicates a required field)

*First Name:		*Last Name:
Address:

City:

State:

Zip Code:

County:

Home Phone:		Business Phone:
Fax:		*Email:

Please indicate the best way to reach you:

Construction Features

Year Built:		Fireplace:
Construction:		Porch:
Square Footage:	feet	Deck:
# of Stories:		Basement:
Garage:		Fire Hydrant:
Bathrooms:		Swimming Pool:

Safety Features

Please check all that apply...

Smoke Detectors

Dead Bolt Locks

Fire Extinguisher

Local Burglar Alarm

Central Burglar Alarm

Central Fire Alarm

If known, please list the coverage limits on your current homeowners policy:

Dwelling:

Other Structures:

Personal Property:

Loss of Use:

Personal Liability:

Medical Payments:

Deductible:

Name of Current Insurance Company:

Are you interested in adding coverage for valuable items? Please indicate amount:

Jewelry:

Furs:

Silverware:

Antiques/Artwork:

Other Information

Please indicate the year the following systems were last updated:

Roof:

Heater:

Electric:

Have there been any homeowners claims within the last three years?

No Yes

If so, explain:

Are there any business activities conducted from the home?

No Yes

If so, explain:

Do you own any other residential properties?

No Yes

Please list addresses and whether owner or tenant occupied:

Comments:

The information supplied will be used solely for the purpose of preparing a quotation
and will not be disclosed to any outside sources not involved in this process.