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Homeowners Insurance Questionnaire
Call Us Today At
(281) 550-5864
Homeowners Insurance Questionnaire
First Name (Primary)
Last Name
Date of Birth
Occupation
First Name (Secondary/Spouse)
Last Name
Date of Birth
Occupation
Property Address (Street, City, State, Zip)
Mailing Address (P.O. Box)
Mobile Phone
Email Address
Referred By
General Information
Quote Type for Property Requested
Property Type
Single Family Residence
Condo
Townhome
Duplex
Fourplex
Apartment
Property Owner Occupied
Yes
No
Do you anticipate that this property will ever be unoccupied For more than 30 days once the insurance coverage is effective?
Yes
No
Property Tenant Occupied
Yes
No
Is this a new purchase?
Yes
No
What is the closing date?
What is your move-in date?
What is your loan amount?
What date should your insurance coverage start?
Please indicate your preferred method of communication
Voice/Phone
Email
Fax
Text
How many years at property requesting quote for:
If residing at property less than 3 years please give previous property address (Street, City, State, Zip)
Property
Year Home Built
Home Sq Footage
1 Story or 2 Stories
# of Bedrooms
# of Bathrooms
Age of Roof
Garage
Attached Garage
Detached Garage
Foundation Type
Slab
Pilings
Piers
Crawl Space
Open Crawl Space Enclosed
Basement
Original Purchase Price
Original Purchase Date
Pool
Yes
No
Dive Board
Yes
No
Slide
Yes
No
Construction
Brick Veneer
Masonary
Stucco
Hardi Plank
Dog on Premise
Yes
No
Dog Breed
Any bite history?
Yes
No
If yes, please give details:
Local Alarm
Smoke Detectors
Burglar
Central Station Monitored Alarm
Fire
Burglar
Property Updates
Electrical Year Complete or Partial
Plumbing Year Complete or Partial
Age of HVAC
Age of Roof
Current Insurance
Current Insurance Company
Annual Premium
Policy Expiration Date
Current Insurance Deductible
Current Windstorm Deductible
Current All Other Perils Deductibles
Fire Department Within 5 Miles of Residence?
Yes
No
Miles to Fire Department
Do you have a flood policy currently enforced?
Yes
No
Insurance Claims
Any claims in last 5 years?
Yes
No
Claim Type?
Dollar Value $ of Claim
Has Damage Been Fully Repaired
Yes
No
Signature
*
Name
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