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Home Insurance Questionnaire
Please
click here for condos.
Closing Date:
Today's Date:
Personal Info:
First Name:
Last Name:
Date of Birth:
Phone Number:
Email Address:
Property Address:
Street Address:
City:
State:
Zip Code:
New Purchase
Yes
No
Previous Insurance Co:
(If not a new purchase)
Purchase Price:
Occupancy:
Primary
Secondary
Tenant
Seasonal
Type:
Homeowners
Contents Only
Rental
Year Built:
Fireplace:
Yes
No
Security System:
Yes
No
Construction:
Block
Frame
Other
Roof Type:
Shingle
Concrete Tile
Tin
Slate
Wood
Clay Tile
Steel Roofing
Roof Shape:
Gable
Hip
Flat
Square Footage:
Swimming Pool
Spa
Hot Tub
Fenced
Screened
Slide
Diving Board
Pool Type:
Above Ground
Inground
Distance to Gulf (miles):
Circuit Breakers or Fuse Box:
Circuit Breakers
Fuse Box
If 30 years old, the year electrical was updated:
Flood Zone:
Yes
No
Animals:
Yes
No
Type:
Amount of Insurance:
Dwelling:
Contents:
Personal Liability:
Trampolines:
Yes
No
Bankruptcy:
Yes
No
Losses in 3 years (on any property):
Mortgage Company/Contact Person:
Phone:
Fax:
Referred By:
