Homeowners Questionnaire

Current Policy Information
Current Ins Co		Exp. Date
Coverage A (Dwelling)
Coverage B (Other Structures)
Coverage C (Contents)
Coverage D (Loss of Use)
Coverage E (Personal Liability)
Coverage F (Medical Payments)
Deductible

Home Description
Style of House		# of Families
Square Footage		Year Built
Electrical	-- Circuit Breaker Fuses	Year Roof Replaced
Year Plumbing Updated		Year Heating System Updated
Basement: % of First Floor:________ % Finished:_______
Garage	-- Yes No	# of cars	-- Attached Detached
Number of Baths	Full   Half	# of Fireplaces
Deck	-- Yes No	Deck Sq Ft
Breezeway	-- None Screened Open	Breezeway Sq Ft
Porch	-- None Open Screened Enclosed	Porch Sq Ft
Exterior Walls	-- Wood Siding Shakes Vinyl Siding Brick	Roof Cover	-- Asphalt Shingles Slate Tile Shakes
Central Heat	-- Yes No	Central AC	-- Yes No
Protective Devices (Burglar Alarms/Fire Alarms)
Swimming Pool	-- No Above Inground	Fence Enclosed	-- Yes No
Own a Dog	-- Yes No	Dog Type
Woodstove Installed	-- Yes No
Any Homeowner Policy claims in the last 3 years -- Yes No If Yes, explain
Do you conduct any business at Home -- Yes No If Yes, explain
Do you store any business property at Home -- Yes No If Yes, explain
Do you have any valuable items that may require a special coverage -- Yes No If Yes, explain
Umbrella Policy	-- Yes No	Policy Limit