Homeowner Questionnaire

Name

Name (Spouse)

Date of Birth

Date of Birth (Spouse)

Phone Number

Email Address or other contact

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 Info:

Year of original construction

Style of original home

Above ground square ft of original home

Below ground construction of original home
—Please choose an option—BasementSlabCrawl

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]?)

# of Baths
(# of Full & # of 1/2)

Central Air
YesNo

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

Flooring
(% of Each Type)

Age & type of roof

Age & type of heating

Age & type of electric
Circuit BreakersFuses

Security or Sprinkler System
(If yes, what?)

Repairs Needed

Current Insurance Info:

Current coverages
(Include company, due date, coverages, deductible & endorsements)

Additional Info:

Purchase date

# 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, bike/skate ramp 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.