Single Family Home Rental Questionnaire CommentsThis field is for validation purposes and should be left unchanged.Name (Include spouse if on title &/or sharing policy rights)Date of BirthSocial Security NumberPhone NumberEmail Address or Other Contact Mailing Address Street Address City State / Province / Region ZIP / Postal Code Property InformationWho is on the title of this property (List individual(s) or business name)Location Address and CountyYear of original constructionAbove ground square footage of original homeStyle of original home (1 storey, etc)Below ground (original home) (Basement/Slab/Crawl: If basement, % finished:)Additions (Year, style, size & below ground construction [incl % finished if basement])Exterior constructionGarage (Yes/No, Attached/Detached, # of Vehicles)Deck, porch, patio, breezeway, etc (Yes/No, Type, Size)Detached Structures (If yes, what? Heated? If yes, by what?)Number of Baths (# of full & # of 1/2)Repairs NeededCentral Air Yes No Fireplace (Yes/No, Gas/Wood/Wood Stove)Flooring: % of each typePool, hot tub or trampoline?Age & type of roofAge & type of heatingAge & type of electric (Circuit Breakers/Fuses)Security or Sprinkler System (If yes, what?)Number of AcresRepairs NeededCurrent Insurance InformationCurrent Coverages (Include company, effective date, coverages, deductible & endorsements)Current coverage settlement (Actual Cash Value/Replacement Cost)Additional InformationPurchase Date or Closing DateALL property claims in the last 5 years (Date,Type,Location,$ Paid)Bankruptcy in the last 5 years (If yes, when?)Is this property CURRENTLY rented? Yes No Are any contents provided? (If yes, please list type and value)Who manages this property? Management Company You Other Deductibles you would considerAdditional InsuredDo you have a Pet Policy/Sub-Lease Policy/Waiver of Subrogation Policy in your lease? (Choose ALL that apply)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.
