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Your name:
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Your email address:
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PHONE:
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Address to be insured.
Note if different than
mailing address
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Type of home: single family
dwelling, apartment, condo,
townhouse or rowhouse
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Number of Bed Rooms:
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Date of home Purchase
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Year built:
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Construction type:
wood frame, joisted masonry
masonry veneer, mfg home, fire
resistive. Also note if you have vinyl
or aluminum siding.
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Square Footage:
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Is this a primary, secondary
or seasonal home?
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Number of families in home?
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What type of heating sytem do
you have?
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Do you have a central station, direct or
local smoke temperature or burglar
alarms, if so confirm type of alarm.
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Number of residents in home:
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Name of local fire
department, district and or
code number if known
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Distance to both a fire hydrant
and local fire station
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Any renovations to the wiring,
plumbing, heating, roofing or
exterior paint? Is so note partial
or complete and year of
renovation.
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Home Heating Type and date
last services if known
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Confirm if you have circuit
breakers, (fuses and or knob,
tube or aluminum wiring):
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Condition of home:
Plumbing system?
Any known leaks?
Housekeeping?
Condition of roof?
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Confirm home has a deadbolt,
fire extinguisher and if it is
visible to neighbors or not:
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Foundation: open, closed or none
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Roof Type? (fiberglass
shingle, etc.)
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Are you an owner or tentant?
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Is home occupied daily?
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If home is rented, confirm #
weeks rented per annum
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Rating Credits? are you a
non-smoking family? Does
home have any lightning
protection ?
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Oil Storage Tanks?
Indoors - Above ground on or off a
masonry floor vs. Outdoors- above
ground or below ground?
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Swimming pool?
If yes, do you have an approved
fence? diving board? slide?
Above or in ground pool?
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Do you have a basement? If
so, what is the square footage?
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Sprinklers?
partial, full or none
Windtorm loss prevention features?
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Do you have a garage or
breezeway? If so, what is the
respective square footage?
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Fire places: (enter number)
chimneys, hearths, pre-fab or wood
stoves:
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Your Occupation and Employers name, please
include years in current occupation, years with
current employer and years with prior
employer if applicable). If co-applicant applies
or self employed, include in description. We
will not contact employer.
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Coverages:
Home / Dwelling Value Amount to be insured? ($)
Other Structures $ amount:
Personal Property to be insured? ($)
Loss of Use amount? ($)
Personal Liability (each occurrence $ amount)?
Medical Payments (each person $ amount)?
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Marital Status
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Dates of Birth for all applicants:
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Social Security #'s of all applicants
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EXPLAIN ALL "YES" RESPONSES IN REMARKS FOR THE BELOW BRIEF QUESTIONS
1. ANY FARMING OR OTHER BUSINESS CONDUCTED ON PREMISES? (Including day/child care)
2. ANY RESIDENCE EMPLOYEES?
3. ANY FLOODING, BRUSH, FOREST FIRE HAZARD, LANDSLIDE, ETC?
4. ANY OTHER RESIDENCE OWNED, OCCUPIED OR RENTED?
5. ANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers)
6. HAS INSURANCE BEEN TRANSFERRED WITHIN AGENCY?
7. ANY COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE LAST 3 YEARS?
8. HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY, JUDGEMENT OR LIEN DURING THE PAST FIVE
YEARS?
9. ARE THERE ANY ANIMALS OR EXOTIC PETS KEPT ON PREMISES? (Note breed and bite history)
10. IS PROPERTY LOCATED WITHIN TWO MILES OF TIDAL WATER? PRIVATE RESIDENCE AND THEN CONVERTED?
11. IS PROPERTY SITUATED ON MORE THAN FIVE ACRES? (If yes, describe land use)
12. DOES APPLICANT OWN ANY RECREATIONAL VEHICLES (SNOW MOBILES, DUNE BUGGYS, MINI BIKES, ATV'S, ETC)?
13. IS BUILDING RETROFITTED FOR EARTHQUAKE? (If applicable)
14. DURING THE LAST FIVE YEARS (TEN YEARS IN RHODE ISLAND), HAS ANY APPLICANT BEEN CONVICTED OF ANY DEGREE OF THE
CRIME OF ARSON?
Qustions # 15-17 For Renters and condos only. 15 Is there are manager on premise? 16. Is there a security attendant? 17. Is the
building entrance locked?
18. ANY UNCORRECTED FIRE OR BUILDING CODE VIOLATIONS?
19. IS BUILDING UNDERGOING RENOVATION OR RECONSTRUCTION? (GIVE ESTIMATED COMPLETION DATE AND $ VALUE)
20. IS HOUSE FOR SALE?
21. IS PROPERTY WITHIN 300 FEET OF A COMMERCIAL OR NON-RESIDENTIAL PROPERTY?
22. IS THERE A TRAMPOLINE ON THE PREMISES?
23. WAS THE STRUCTURE ORIGINALLY BUILT FOR OTHER THAN A PRIVATE RESIDENCE AND THEN CONVERTED?
24. ANY LEAD PAINT HAZARD?
25. IF A FUEL OIL TANK IS ON PREMISES, HAS OTHER INSURANCE BEEN OBTAINED FOR THE TANK? (Give First Party and limit, and
Third Party and limit)
26. IF BUILDING IS UNDER CONSTRUCTION, IS THE APPLICANT THE GENERAL CONTRACTOR?
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Comments:
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