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Personal Homeowner Quote Questionnaire

Personal Homeowner Quote Questionnaire

Personal Homeowner Quote Questionnaire

Date

MM slash DD slash YYYY

Referred by

Applicant 1

First Last

DOB

MM slash DD slash YYYY

Applicant 2

First Last

DOB

MM slash DD slash YYYY

Phone

Ok to leave message?

Yes

No

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Prior Address if less than 3 years

New Purchase?

Yes

No

Closing Date

Purchase Price

Home Information

Year Built

Square Footage

# of Stories

Foundation

Basement Finished

Yes

No

% Finished

Walkout?

Yes

No

Exterior Wall Finish

Garage

Yes

No

Attached?

Yes

No

# of Cars

# of Bathrooms

Finish

Builders Grade

Custom

# of Kitchens

Finish

Builders Grade

Custom

Flooring Types

Wood Burning Stove

Yes

No

Fireplace

Yes

No

If yes, how many?

Gas or solid fuel?

Deck

Yes

No

Square Footage

Porch

Yes

No

Square Footage

Central Air?

Yes

No

Type of Heat

Year of Update To:

Roof

Wiring

Plumbing

Heating

Central Fire Alarm?

Yes

No

Central Burglar Alarm?

Yes

No

Smoke Detectors?

Yes

No

Trampoline?

Yes

No

Anchored?

Yes

No

Netting?

Yes

No

Fenced Yard?

Yes

No

Pool?

Yes

No

Fenced?

Yes

No

Special Features

Sauna, wet bar, skylight, wine cellar, greenhouse, large windows, fench doors, etc

Mortgage on the home?

Yes

No

Mortgagee

Home deeded to anyone else, trust, or LLC?

Yes

No

If yes, name?

Deductible

Other Deductible

Water back up of sewer and drain

Limit Desired?

Earthquake Coverage

Yes

No

Earthquakes are not covered by a stardard homeowners policy

Flood Quote

Yes

No

Floods are not covered by a stardard homeowners policy

Umbrella Quote

Yes

No

General Questions

Will the home be occupied?

Yes

No

Do you own any revreational vehicles?

Yes

No

Do you own any watercraft?

Yes

No

Do you own any hight value jewelry items?

Yes

No

Any buisness operated out of the home?

Yes

No

Do you have a nanny?

Yes

No

Are there any pets on the property?

Yes

No

Types?

Do you rent your home or part of your home?

Yes

No

Such as VRBO, Airbnb, or Home Share?

Additional Information on Applicants

Occupation

Co-Application Occupation

Group Affiliations

AARP, Alumni Member, Medical Association, Chamber Member, etc

Prior Carrier

Expiration Date

Home claims past 5 years

Additional Remarks

Location

1793 W Stadium BlvdAnn Arbor, MI 48103

Contact Us

O: 734-327-9222
F: 734-327-9225

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