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Spanish (Latin America)
Thank You For Completing Our Homeowner's Survey
In order to provide you with the most accurate analysis of insurance available with the top carriers, please complete this survey. Your help with answering these questions will prevent incorrect quotes and will limit contacting you for needed information.
Primary Insured Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Date of birth
-
Month
-
Day
Year
DOB
Marital Status
Married
Single
Divorced
Widowed
Co-Insured Name
First Name
Last Name
Co-Insured DOB
-
Month
-
Day
Year
DOB
Marital Status
Married
Single
Divorced
Widowed
How many years have you been with your current homeowners insurance company?
How many years have you been continuously covered with homeowners insurance?
Property Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you rent or own it?
RENT
OWN
When was your home built?
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
When did you purchase your home?
-
Month
-
Day
Year
Date
Property Type
Single Family Home
Semi-attached
Townhouse
Condo
Co-op
Multi-unit
What type of building is it?
Single family
Duplex
Triplex/Fourplex
How would you describe the condition of the Exterior & Interior?
Needs work
Standard
High
Excellent
Number of stories
Please Select
1
1.5
2
3
4
What is the square footage of your home (excluding basement)?
Square Footage
Is your basement finished?
Unfinished
Partially Finished
Fully Finished
Total square footage (including any finished portion of basement)?
Square Footage
In what year was your roof last replaced (your best recollection)?
Additional updates to the house
Heating Update
Electrical Update
Plumbing Update
If yes to any, please describe in detail
Who lives in your home?
Me Only
Me and my spouse
Me, spouse & children
Me and my children
Other
Total number of residents in your home?
Type of construction
Please Select
Frame
Joisted Masonry
Brick
Non-Combustible
Masonry Non-Combustible
Fire Resistive
I don't know...
Type of siding
Please Select
Shingles
Vinyl
Wood Shake
Brick
Other
How do you heat your home?
Gas
Oil
Other
Do you have any personal belongings of high value? (EX: Jewelry, Furs, Art)
Do you have any pets?
Yes
No
If so, describe any pets including breeds.
Is there any bite history?
Yes
No
If so, then please describe.
Do you have an in-ground pool?
Yes
No
Do you have any of the following?
Fire alarm
Burglar alarm
Have you filed any home or property claims within the past 5 years?
Yes
No
If so, then please describe in detail
Optional. Please upload a copy of your current homeowners insurance declaration pages.
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