Homeowners Questionnaire for Quoating

Name:
Phone 1:
Phone 2:
Email:
Insured 1 Name:
Insured 1 DOB:
Insured 1 SS:
Insured 1 Occupation:
Insured 2 Name:
Insured 2 DOB:
Insured 2 SS:
Insured 2 Occupation:
Previous Address:
Years
Current Address:
Years
Why Us?
Loses?
Insured Now?
Insurer?
Expiration?
Why Changing?
Mortgage?
Purchase Price?
Closing Date?
Year Built?
Square Feet?
Style?
Construction?
Stories?
Familes?
Circuit Breakers?
Fuses?
Knob & Tube Wiring?
Fuel Oil Tank Location
Hydrant Distance
Updates:
Roof
Electrical
Heat
Plumbing
Fireplaces
Centeral Burglary Alarm
Centeral Fire Alarm
Sprinkler Percentage
Animals
Bite History
Wood Stove
Professionally Installed
Trampoline
Waterfront Docks
Flood Insurance
Current Limits
Coverage A - Dwelling
Coverage E - Personal Liability
Hurricane Deductible
Coverage B Other Structures
Coverage C Contents
Coverage D Lose of Use

Open Monday through Friday 8:30AM to 4:30PM
Phone: (860)535-1859
Fax: (860)535-4819

530 Stonington Road Suite 104
Post Office Box 311
Stonington, CT 06378-0311