Homeowner's Questionnaire

Insured

  • First name:
  • Last name:
  • Date of birth:
  • Social security number:

Spouse

  • First name:
  • Last name:
  • Date of birth:
  • Social security number:

Dwelling Information

  • Year built:
  • Number of stories:
  • Roof type:
  • Total square footage of first floor:
  • Number of full baths:
  • Garage:
    Yes No
  • If yes, how many vehicles:
  • Deck:
    Yes No
  • If yes, what size:
  • Swimming pool:
    Yes No
  • If yes, what type:
    Above ground In ground N/A
  • Finished basement:
    Yes No
  • Pets:
    Yes No
  • If yes, what type:
  • Type of heating:
  • Number of bedrooms:
  • Number of half baths:
  • Number of walk-in closets:
  • Fireplace:
    Yes No
  • If yes, how many:
  • Woodstove:
    Yes No
  • If yes, how many:
  • Porch:
    Yes No
  • If yes, what size:
  • Security system:
    Yes No
  • If yes, what type(s):
    Central Station Fire Burglar

Dwelling Updates

Please enter year completed for each item.
  • Electrical:
  • Heating:
  • Plumbing:
  • Roof: