Homeowners Questionnaire Homeowners Questionnaire First Name Insured(Required) Date of Birth:(Required) MM slash DD slash YYYY Social Security Number(Required) Additional Named Insured Date of Birth: MM slash DD slash YYYY Social Security Number Phone NumberEmail Current Address Property Address New Purchase Yes No Occupied Tenant Owner Home Currently in Foreclosure Yes No Effective/Closing Date MM slash DD slash YYYY Year Built MM slash DD slash YYYY Total Square Footage Year of Updates - Roof Year of Updates - Heating Year of Updates - Plumbing Year of Updates - Wiring Home Currently Vacant(Required) Yes No Type of Heat(Required) Gas Oil Was there an Oil Tank Ever on Premise(Required) Yes No If Type of Heat is Oil - Tank Location(Required) If Home Currently Vacant is YES - Number of Days(Required) Number of Stories(Required) Number of Families(Required) Basement(Required) Finished Unfinished Style of the Home(Required) Ranch Cape Code Split Level Colonial Other If Other Style of the Home(Required) Construction Type(Required) Frame Masonry Other Exterior(Required) Vinyl Siding Brick Stucco Other If Other Construction Type(Required) If Other exterior(Required) Number of Rooms Number of Bathrooms Foundation(Required) Slab Crawl Space Basement Basement(Required) Pitched Flat Garage(Required) Yes No If Garage is yes - Type Attached Detached Built-in Pool(Required) Above Ground In Ground No pool Diving Board(Required) Yes No Slide(Required) Yes No Trampoline(Required) With Net Without Net No trampoline Dog(Required) Yes No Breed(Required) Bite History(Required) Yes No Explain the bite history(Required) InsuranceCurrent/Prior Insurance Co.(Required) Policy Expiration Date(Required) MM slash DD slash YYYY Claims(Required) Yes No Explain claims(Required) Coverage LimitsDwelling Amount Liability Amount Deductible Umbrella Limit MortgageLender Closing date MM slash DD slash YYYY Loan Number
