Single Family Home Rental Questionnaire Personal Info: Name (Include spouse if on title &/or sharing policy rights) Date of Birth Social Security Number Phone Number Email Address or Other Contact Mailing Address Property Info: Who is on the title of this property (List individual(s) or business name) Location Address and County Year of original construction Style of original home (1 storey, etc) Above ground square footage of original home Below ground (original home) (Basement/Slab/Crawl: If basement, % finished:) Additions (Year, style, size & below ground construction [incl % finished if basement]) Exterior construction Garage (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?) # of Baths (# of full & # of 1/2) Repairs Needed Central Air YesNo Fireplace (Yes/No, Gas/Wood/Wood Stove) Flooring: % of each type Pool, hot tub or trampoline? Age & type of roof Age & type of heating Age & type of electric (Circuit Breakers/Fuses) Security or Sprinkler System (If yes, what?) Number of Acres Repairs Needed Current Insurance Info: Current Coverages (Include company, effective date, coverages, deductible & endorsements) Current coverage settlement (Actual Cash Value/Replacement Cost) Additional Info: Purchase Date or Closing Date ALL 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? YesNo Are any contents provided? (If yes, please list type and value) Who manages this property? Management CompanyYouOther Deductibles you would consider Additional Insured Do 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.