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Home Insurance Questionnaire

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Personal Lines Home Questionnaire

County
County


Form: HO3 Renters (HO4) Condo (HO6) Rental Dwelling Seasonal

Current Limits
Non-Smokers?
Yes
No
Coverage A
Alarm System?
Yes
No
Coverage B
If yes to Alarm Local Police Central
Coverage C
Smoke Dectectors?
Yes
No
Coverage D
Fire Extinguisher?
Yes
No
Coverage E
Dead Bolt Locks?
(on every exterior door)
Yes
No
Coverage F
Sump Pump?
Yes
No
Deductible
Wood Stove?
Yes
No
Current
Market Value
Swimming Pool?
Yes
No
If Rental Property
Above Ground?
Yes
No
Is home occupied? Yes No
Swimming Pool Fence ?
Yes
No
If not, when?
Pool Fence Locked?
Yes
No
Monthly Rent?
Swimming Pool Fence Height
Value of Landlord's Contents $
Diving Board?
Yes
No
Note: photos are required
to bind coverage
Home Business?
Yes
No
Watercraft?
Yes
No
What Year Were the
Following Systems Updated?
Trampoline?
Yes
No
Plumbing
Hot Tub?
Yes
No
Electrical
Hot Tub Locked Cover?
Yes
No
Heating
Dogs?
Yes
No
Air Condition
How Many Dogs?
Roof
Breed(s)
Any Claims in the last 5 Years
Y
es (complete below) No
Date Type Paid $
Date Type Paid $
Date Type Paid $
Schedule of Personal Property
Jewelry: # of items Total Value $
Furs: # of items Total Value $
Fine Arts: # of items Total Value $
Replacement Cost Information
Year Built:
No. of Families 1 2 3 4
Number of Stories : 1 1.5 2 3 Tri-Level Bi-Level
Exterior Wall Material: Frame % Masonry Veneer % Masonry %
Square Footage: 1st Level 2nd Level 3rd Level
Basement: sq feet Crawl Space Slab Walkout
Yes No Garage: Attached Detached 1 car 2 car 3 car 4 car
Built In Basement Carport
Yes No Finished Attic: sq. feet
Yes No Air conditioning: Using heating ducts Seperate Ducts
Yes No Attached Three-Wall Room Addition: Sq. Feet 1 Story 1.5 Story
2 Story Masonry/Brick Veneer Frame With Basement
Without Basement 1 Story Over Garage Stories over Garage
Yes No Breezeway: Square Feet Open Wall Enclosed Wall
Yes No Porch: Square Feet 1 Story 1 Story with sundeck 2 Story
Open Wall Enclosed Wall
Yes No Decks or Balconies: Square Feet
Yes No Fireplace: Number of Chimneys Number of Hearths
Yes No Baths: Total Number of Full Baths Total Number of Half Baths
Yes No Screened Aluminum Enclosure: sq feet
On Posts Slab
Foundation Wall

Built-Ins: Please check all that apply
Skylight Jacuzzi/Jet Tub Water Softener Counter-Top Range Sauna
Intercom Central Stereo System Central Vacuum Double Oven Oven
Wet Bar Prefab Fireplace Insert Ceiling Fan Other please specify

Floor Coverings: Carpet % Hardwood % Tile %
Linoleum % Parquett% Pergo %
Window Types: Oversized Picture Windows # Sliding Glass Doors # Arched #
French Doors #(Interior/Exterior) Bay # Bows # Stained Glass# Garden#
Notes to Agent (Please give details regarding Home Business or Watercraft, etc)