California Insurance License Number 0E83160
HOME INSURANCE QUESTIONNAIRE (for Home Owner)
Please provide the following contact information: ALL QUESTIONS THAT ARE APPLICABLE MUST BE ANSWERED
Name Mailing Address City Zip Code Current Ins. Co. Current Ins. Expiration Date (Format Month/Day/Year; mm/dd/yyyy) Primary Phone # E-mail Address Property Information Property Address City: Zip Code: Type of Property Primary Home Secondary Residence Rented to Others Any claim within 5 years Yes No If answer is Yes, type of Loss Water Damage Liability Burglary Other Year Built: Type of Roof: Tile Composition Wood Shake Other Type of Exterior: Stucco Wood Siding Other Is Residence:I 1 Story 2 Story Living Area Sq. Feet How many Bedrooms How many Bathrooms Full Half Three Quarter Breezeway / Balcony: SQ Footage Garage Size: 1 Car 2 Cars 3 Cars Garage Type: Attached Under 2nd Floor Detached Car Port Any Extra Structure Pool Pond Jacuzzi Patio Is Your Patio Covered Enclosed SQ Footage Wood Decks SQ Footage Fire Place YES NO How many? Do you have any PETs? YES NO If pet is a dog: How many? what type of breed Any bite history? YES NO Any type of formal training? YES NO Any discount Burglar Alarm: None Central Fire Alarm: None Central ** Proof Required Later ** Property Upgraded Information Roof Updated: year Wiring Updated: year Heating Updated: year Plumbing Updated: year Coverage Liability: $100,000 $300,000 $500,000 Medical: $1,000 $2,000 $3,000 $5,000 Deductible: $100 $250 $500 $1,000 $1,500 $2,500 Remarks Note: IF YOU HAVE ANY VALUABLE ART WORK EXTENSIVE AMOUNTS OF JEWELRY, THESE ITEMS SHOULD BE INSURED SEPARATELY, OTHER ITEMS AND COLLECTABLES SHOULD ALSO BE INSURED SEPARATELY, WE WILL ADVISE YOU OF THESE ITEMS AT A LATER DATE.
Property Information
Do you have any PETs?
If pet is a dog:
Any discount
Property Upgraded Information
Coverage
Remarks
Note: IF YOU HAVE ANY VALUABLE ART WORK EXTENSIVE AMOUNTS OF JEWELRY, THESE ITEMS SHOULD BE INSURED SEPARATELY, OTHER ITEMS AND COLLECTABLES SHOULD ALSO BE INSURED SEPARATELY, WE WILL ADVISE YOU OF THESE ITEMS AT A LATER DATE.