Homeowners Questionnaire

Homeowners Insurance Questionnaire

Please complete the form below. All fields marked with an asterisk (*) are required. CA DOI License No. #0H55923

1. Named Insured & Contact Information

Named Insured

SSN

Date of Birth

Occupation & Employer

Second Named Insured (Optional)

Mailing Address

Day Phone

Home Phone

E-Mail

2. Property & Construction Details

Property Address [Same as Mailing]

Year Built

Construction Type

Number of Stories

Square Footage

Type of Roof

Last Replaced (Year)

Are There Any Other Structures (e.g. Workshop / Pergola) on the Property?

Yes No

3. Features, Heating & Security Systems

Do You Have a Pool, Hot Tub, Golf Cart or Trampoline?

Yes No

Do You Have a Dock?

Yes No

Number of Fireplaces

Number of Chimneys

Full Baths

¾ Baths

Half Baths

Type of Heating System

Security System?

Yes No

4. Updates (If House Is Over 25 Years Old)

If your home is over 25 years old, please indicate recent updates, dates completed, and scope of work done:

Electrical System

Date Updated

What Was Done

Plumbing System

Date Updated

What Was Done

Roof Replacement / Repair

Date Updated

What Was Done

5. Property Occupancy, Use & Liability Hazards

Is There a Mortgage on the Property?

Yes No

Do You Rent a Room(s) to Someone?

Yes No

Do You Own a Dog?

Yes No

Do You Run a Business or Conduct Any Business Operations Aside from Incidentals from Your Residence Premises?

Yes No

Do You Store Any Business Personal Property at Your Residence Premises?

Yes No

Do You Have Any Hobbies That Generate Revenue?

Yes No

6. Insurance History & Prior Losses

Current Homeowner's Insurance Carrier

Have You Been Non-Renewed and/or Had Your Homeowner's Policy Canceled for Any Reason in the Last 5 Years?

Yes No

Any Losses (Property or Liability) in the Past 5 Years?

Yes No

7. Additional Coverage Quotes Requested

Quote for Earthquake?

Yes No

Quote for Flood Insurance?

Yes No

Protects against external rising waters & mudflows.

Quote for an Umbrella?

Yes No

Extra liability protection ($1M-$5M+) over home & auto.

Are You a Human? Please Answer the Math Question Below:

We respect your privacy. Your information will only be used to process your insurance quotes and verify underwriting eligibility.

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16461 Sherman Way Suite 350
Lake Balboa, CA 91406
(818) 464-4444

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12819 SE 38th St. Suite 430
Bellevue, WA 98006
(206) 690-5580

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