Homeowner Questionnaire

Phone

This field is for validation purposes and should be left unchanged.

Name(Required)

Date of Birth

Phone Number

Email Address or Other Contact

Name (Spouse)

Date of Birth (Spouse)

Location Address

(Please also list mailing address if different) (If you've lived at this address less than 5 years, please list prior address also)

Construction Information

Year of Original Construction

Style of Original Home

Above ground square ft of original home

Below ground construction of original home

(Basement/Slab/Crawl: If basement, % finished:)

Additions

(Year, style, size & below ground construction. Including % finished if basement.)

Exterior Construction

Garage

(Yes/No, Attached/Detached, # of Vehicles)

Deck, porch, patio, etc

(Yes/No, Type, Size)

Detached Structures

(If yes, what? Heated [If yes, by what]?)

Number of Baths (# of full & # of 1/2)

Central Air

Yes

Fireplace (Yes/No, Gas/Wood/Wood Stove)

Flooring: (% of each type)

Age & Type of Roof

Age & Type of Heating

Age & type of electric (Circuit Breakers/Fuses)

Security or Sprinkler System (If yes, what?)

Repairs Needed

Current Insurance Information

Current Coverages (Include company, effective date, coverages, deductible & endorsements)

Additional Information

Purchase Date

Number of consecutive years you've carried a homeowner-type policy?

(Including home, condo, mobile home & tenant)

Valuable Contents (Type & Value)

(ie Jewelry, Guns, antiques, artwork, etc)

Have you filed a homeowner claim in the last 5 years on any property? (If yes, please list when and what)

Smoker/Non-Smoker (All residents)

Bankruptcy in the last 5 years? (If yes, when?)

Is there a pool, hot tub or trampoline on your property? (If yes, what?)

Do you have any pets or livestock? (If yes, what breed?)

Business conducted in your home? (If yes, what?)

How many acres does your home sit on?

Do you own any other properties?

Deductible options you would consider

Additional Insured

Do you have any toys?

(ie boat, motorcycle, ATV, snowmobile, golf cart, RV, etc)

If you have a copy of your current "Declaration Page", please forward that to us as proof of prior coverage and to use for comparison purposes. Submission of information for a quote in no way binds coverage. Personal information will be used solely for underwriting purposes. Submission of information gives the Gary J Bach Agency permission to run all reports necessary to quote accurate insurance premiums.