Homeowner Information For Your Agent

To assist you when talking to an independent insurance agent about homeowner insurance, take a few minutes and answer the following questions. This will help prepare you to answer some of the questions they will be asking regarding your insurance needs.

  • You may complete the form online by entering your information in the appropriate fields. Forms completed online may be printed (by selecting "File, Print" from the browser tool bar).
  • You may also print the form (by selecting "File, Print" from the browser tool bar) and complete it by hand.

I would like insurance for the following property where I reside/rent to others. (circle one)

Address: City: State: ZIP Code:

Property is a: Construction is: Siding type is:
Home (sq. ft. ) Frame Aluminum
Condominium Masonry Plastic/Vinyl
Apartment Masonry Veneer Cedar
Townhouse Other Other
Other    

My home has the following:

Kitchen Library Wood/Pellet Stove
Dining Room Laundry Room Finished Basement
Living Room Bathrooms (full) Attached Garage (# of Stalls )
Great Room Bathrooms (half) Detached Garage (# of Stalls )
Bedrooms (# ) Chimney Shed
Family Room Fireplace Other

My home also has the following:

Burglary Protection: Fire Protection: Animals or Exotic Pets:
Central Alarm Central Station Dog(s) (# )
Direct Alarm Direct Station Breed:
Local Alarm Local Station Other:
Deadbolt Lock(s) Smoke Alarms Other:
  Fire Extinguishers Other:

The year my home was built: . (If greater than 50 years old, have the following been updated and when):
Electrical: Y/N Date: Plumbing: Y/N Date: Heating: Y/N Date:
Roof: Y/N Date:

Distance to the local fire department is miles. Name of the department:
Distance to the nearest fire hydrant feet.

I have a mortage on my home which is with: (Financial Institution)
Address:

My name:
Address (if different than listed above):

Disclaimer: While Personal Insurance Center can assist you in assessing your insurance needs, the content of this site is for informational purposes only. Contact your independent agent for a complete analysis of your insurance needs and specific policy terms and conditions.