Personal Lines Questionnaire

Name*

First

Last

Spouse

First

Last

Date

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Email*

Cell Phone

Home Phone

Auto Quote*

Yes
No

Home Quote*

Yes
No

Rent or Own?

Current Liability Limits

Current Insurance Carrier

How long with Carrier?

Expiration Date

Please list ALL people in our household of driving age:

Name*

First

Last

Date of Birth

Drivers License Number

Occupation or Student?

Tickets/Accidents in the last 5 years

Please list your vehicles

Year

Make

Model

VIN Number

Comprehensive Deductible

Collision Deductible

Vehicle Use

Driver

Address where vehicle is garaged

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Lineholder

Homeowner Info

Address if different than residence

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Within City Limits?

Inside
Outside

Miles to Fire Department

Distance from Fire Hydrant

Number of acres, if any

Livestock?

Yes
No

How long have you lived at current address?

Prior address if less than 3 years

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Coverage limit on Dwelling

Year Built

Square Feet

Number of stories

Roof type

Age of Roof

Foundation type

Exterior Construction

Brick Veneer
Frame
Stucko
Other

If Other

Heating

Electric
Gas

Number of full bathrooms

Number of half-baths

Fireplace?
Trampoline?

Size of Garage

1
2
3
4

Style of Garage

Attached
Detached

Pool or Porch/Deck?

Pool
Porch or Deck

Is pool fenced & locked?

Yes
No

Type and size?

Pets?

Yes
No

Breed(s)

Monitored Alarms?

Yes
No

Company

Smoke Detectors?

Yes
No

Custom Features

Type of Flooring by Percentage

French Doors?

Yes
No

How many?

Type of Countertops

Construction Type

Designer
Custom
Semi-Custom
Builders Grade

List items you are specifically concerned about insuring (jewelry, watches, antiques, etc.)

Is your home over 15 years old?

Yes
No

What year was the roof replaced?

What year was the electrical wiring updated?

What year was the plumbing updated?

What year was the AC/Heating updated?

Details of Updates

List any claims in the last 5 years:

Date of Loss

Type of Loss

Amount Paid

*YOUR CREDIT, CLAIM HISTORY AND MOTOR VEHICLE REPORTS WILL BE ORDERED DURING THE QUOTING PROCESS AND IS KEPT CONFIDENTIAL*

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