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Personal Lines Insurance
Homeowners Worksheet
Background Information
Date
(required)
Referred By
Your Name
(required)
Street Address
(required)
City / Township
(required)
Zip
(required)
Home Telephone
(required)
Work Telephone
Email
(valid email required)
Year Built
Market Value
City Limits or Name of Township
Purchase Price
Closing Date
Exterior Frame
Masonary Veneer
Masonary
Stone
Other
Substructure
Please make a selection
Basement
Crawl Space
Slab
Don't Know
Number of Stories
Please make a selection
1
1.5
2
2.5
Bi Level
Tri Level
Feet to nearest fire hydrant
Please make a selection
0 to 10
11 to 20
21 to 30
31 to 40
41 to 50
51 or more
Miles to nearest fire department
Please make a selection
0 to 10
11 to 20
21 to 30
31 to 40
41 to 50
51 or more
Total Sq Ft.
Basement
Walkout Basement
No
Yes
Basement Finished?
No
Yes
If yes, what % is finished?
Porch
Is there a porch?
Yes
No
If yes, open or closed?
Open
Closed
No porch
If yes, what is sq. ft. of porch?
Air Conditioning
Central Air Conditioning
Yes
No
Wall A/C Units
Yes
No
Garage / Fire Places
Garage Size
Please make a selection
1 car
2 car
3 car
No Garage
Structure
Attached
Frame
Brick
No Garage
Fire Place
Please make a selection
Gas
Log
No Fire Place
Chimneys
Please make a selection
0
1
2
3
Hearths
Please make a selection
0
1
2
3
Decks / Balconies
Do you have a deck?
Please make a selection
No
Yes
If yes, what is the sq.ft.
Do you have a balcony?
Please make a selection
No
Yes
If yes, what is the sq.ft.
Bathrooms
How many full bathrooms?
Please make a selection
0
1
2
3
4
5
6
7
How many half bathrooms?
Please make a selection
0
1
2
3
4
5
6
7
Modifications
Renovation Types
Wiring
Please make a selection
Full
Partial
None
If yes, what year(s)?
Plumbing
Please make a selection
Full
Partial
None
If yes, what year(s)?
Heating
Please make a selection
Full
Partial
None
If yes, what year(s)?
Roofing
Please make a selection
Full
Partial
None
If yes, what year(s)?
Room Additions
Stories
0
1
2
Basement
No
Yes
If yes, what is sq.ft.?
Finished Attic
No
Yes
If yes, what is sq.ft.?
Structure
Frame
Brick
None
Protection Services System
Smoke
Please make a selection
Central
Direct
Local
None
Fire
Please make a selection
Central
Direct
Local
None
Burglar#Please make a selection
Deadbolt
Yes
No
Fire Exit
Yes
No
Built In Features
Please choose any feature ONLY if permanently built into home
Air Humidifier
Attic Fan
Bathroom Heater
Ceiling Fan
Hot Tub
Radiant Floors
Foundation
Ceramic/Marble Tile
Windows/Bay/Picture
Central Vac System
Skylight
Electronic Air Filter
Elevator
Wet Bar
Intercom System
Cathedral Ceilings
Wood or Sheet Panel
Door/Leaded/French
Sauna/Jacuzzi
Smoke Detectors
Interior Sprinkler System
Video Door Answering System
Whole House Fan
Central Stereo System
Walls (Plaster, Dry Wall, etc)
Floor Covering/Carpet/Vinyl/Tile
Other Structures/Pole Barn/Dish
Applicant Information
Applicant’s Occupation
Applicant Employer Name
Applicant Employer Location
Number of years in current occupation
0 to 5
6 to 10
11 to 15
16 to 20
21 or more
Number of years with current employer
0 to 5
6 to 10
11 to 15
16 to 20
21 or more
Marital Status
Single
Married
Divorced
Widowed
DOB (Date of Birth)
Co-Applicant’s Occupation
Co-Applicant Employer Name
Co-Applicant Employer Location
Number of years in current occupation
0 to 5
6 to 10
11 to 15
16 to 20
21 or more
Number of years with current employer
0 to 5
6 to 10
11 to 15
16 to 20
21 or more
Marital Status
Single
Married
Divorced
Widowed
DOB (Date of Birth)
Payment Plan
Payor
Mortgage Compnay
Mortgage Address
General Information
Any full time residence employees?
Yes
No
Is property situated on more than five acres?
Yes
No
Any business conducted on premises?
Yes
No
If yes, please indicate type of business
Any other insurance with this company?
Yes
No
Is property located near a body of water?
No
Yes
Member of a group, credit union, alumni association or professiona l affiliation?
Yes
No
Any coverage declined, cancelled or nonrenewed during the last three years? (not applicable in MO)
Yes
No
Has applicant had a foreclosure, repossession or bankruptcy during the past five years?
Yes
No
Do you have any pets?
Yes
No
If yes, any behavioral issues?
No
Yes
Are there any separate structures on the property?
No
Yes
Any other residence owned, occupied or rented?
No
Yes
Does applicant own any recreational vehicles?
No
Yes
If yes, please make a list
(snowmobiles, dune buggies, mini bikes, ATVs, etc? list year, type, make, model)
Structures rented to others - residence premises?
No
Yes
During the last ten years, has any applicant been convicted of any degreee of the crime of arson?
No
Yes
Do you want backup of sewer and drain (sump pump) coverage?
Yes
No
Have all household members been disclosed? (Please include children information in Remarks below)
Yes
No
If no, please list additions
Have you turned in any claims within the past 5 years?
No
Yes
Do you have a pool or trampoline on premises?
Yes
No
If yes, is the yard locked and fenced?
Yes
No
Do you have any scheduled items such as jewelry, Furs, silverware, firearms, etc?
No
Yes
Prior Coverage
Prior Carrier
Policy # / Expiration Date
Risk new to agency?
No
Yes
Coverages to Quote
Prospect Name
Type of Poilicy
Dwelling
Liability
Medical Payments
Deductible
Replacement Cost to Dwelling
Yes
No
If yes, what %
Replacement Cost contents#Yes#No
Back up Sewer and Drain
Other Misc. Coverage
$
Multiple Policy Discount
Yes
No
If yes, with all companies or just with
Claims in the last 5 years?
Yes
No
If yes, then please explain
Miscellaneous
Remarks
Feel free to use this area for any information regarding your home and contents that you would like us to have when providing you with a quote.
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