1 home Owners Insurance Questionnaire Name Address of home (including ZIP). Age of owner Currently insured with Underwriting Questions Tyoe of residence HO3 - Standard home Owners HO4 - Renters policy HO6 - Condo/Townhome policy Year built Type of constuction Frame Mason Type of roof Heat source Trampoline Yes No Swimming pool Yes No Wood stove Yes No How many Fireplace Yes No How many Business in home , if yes please explain Yes No Do you have any animals? Yes No Do you smoke Yes No Miles to nearest firestation Feet to nearest hydrant Deductible 250 500 750 1000 2500. Claims in the last 3 years, if yes please explain Yes No Additional Coverages Earthquake Yes No If yes what deductible?
2 Flood Yes No If yes what deductible? Scheduled personal property if any: 1. 2. 3. 4. 5. 6. Additional needs or concerns with your policy