Homeowners Insurance Questionnaire | Select Underwriters Inc

First Named Insured:

DOB:

SSN:

Spouse/Second Insured:

DOB:

SSN:

Mailing Address:

Email:

Cell Phone:

Home Phone:

Effective Date:

Move In Date:

PRIOR INFORMATION

Prior Address:

Prev Insurance Co:

# Yrs with Coverage:

Premium ($):

# of Claims During the Last Five Years:

Date of Loss	Cause of Loss	Approx Payout($)
date	cause	approx
date	cause	approx
date	cause	approx

PROPERTY INFORMAITON

Property Address:

Year Built:

Above Grade Square Footage:

No. of Stories:

Basement:

% Finished:

Garage:

# Car Spaces:

Porch:

Total size of Porch(es):

Deck:

Total size of Deck(s):

# Fireplaces:

Woodstove:

# of Kitchens:

Quality:

Central A/C:

Oil Tank:

# Full Baths:

Quality:

# Half Baths:

Quality:

Deadbolt:

Back Up Generator:

Fire Extinguishers:

Water Back-Up Of Sewers & Drains

Less than 1,000 feet from fire hydrant?

Other Structures?

Construction	Type/Material	Year of Renovation
ROOF	ROOF	Roof
HEAT	HEAT	Heat
ELECTRIC/WIRING	electric	electric
PLUMBING	Plumbing	Plumbing

Safety Devices	Local or Centrally Monitored by 3rd Party
FIRE	fire_select
BURGLAR	burglar_select
SPRINKLER	sprinkler_select
WATER MONITOR	water_select

SCHEDULED ARTICLES ($)

Jewelry ($):

Fine Arts ($):

Computers ($):

Silverware ($):

Business Property ($):

Guns ($):

Other(s):

PROPERTY LIABILITY EXPOSURES

Pets:

Breed & Bite History?

In-Home Business:

Employees:

Details:

Pool:

Fenced:

Trampoline:

Other Residences (Own/Rent/Occupy):

Airbnb/VRBO: