Questionnaire Selection Coverage List

Category: Personal Risks Risk: Single Family Owner Occupied

GENERAL CLIENT INFORMATION

Account: ___________________________________________________________

Account Number: ____________________________________________________

Agency: ____________________________________________________________

Agency Number: _____________________________________________________

Producer: __________________________________________________________

Producer Number: ___________________________________________________

NAMED INSURED(S) __________________________________________________________________

MAILING ADDRESS___________________________________________________________________

Home: Telephone: _____________________

           Email: _________________________

           Fax: ___________________________

Work: Telephone: ______________________

           Email: _________________________

           Fax: __________________________

Cell phone numbers:

           Named Insured - __________________

           Spouse - ________________________

           Others: _________________________

Marital Status: [  ] Married [  ] Single [  ] Divorced [  ] Separated [  ] Other ___________________________

Spouse/Significant Other: ___________________________

List below all people who currently reside in the household including:

Family members

Persons under 21 in the care of the insured (including foster children)

Other nonrelated residents (significant others, roomers, boarders, tenants, domestic employees)

List below all family members who currently do not reside in the household including noncustodial children, college students away at school, or any family living in an assisted living / skilled facility, etc.

Is any property held in a trust? ___ Yes ___ No

Trust Name: __________________________________

Trustees: ____________________________________

Property: ____________________________________

Is the residence a historical landmark or showcase home? ___ Yes ___ No

If yes, are tours provided? _________ # of people________________

Is the property used for community activities? ___ Yes ___ No

If yes, describe the activities ________________________________________________

_______________________________________________________________________

Does the insured belong to a homeowners or condominium owners association? ___ Yes ___ No

If yes, attach a copy of the Association agreement and bylaws.

Is the residence located in a flood plain? ___ Yes ___ No

If yes, does the insured carry flood insurance? ___ Yes ___ No

Is the residence located in a known earthquake area? ___ Yes ___ No

If yes, does the insured carry earthquake insurance? ___ Yes ___ No

Does the insured carry firearms or have firearms in the residence? ___ Yes ___ No

If yes, please complete the firearms supplement.

Have there been any water-related losses (including backup of sewers or drains)? ___Yes ___ No

If yes, what items remain in the home that were damaged and repaired instead of being replaced?

___________________________________________________________________________

___________________________________________________________________________

Is there any evidence of water leaking or seeping in the residence? ___Yes ___ No

Are there any odors in the house that could indicate the presence of mold? ___Yes ___ No

Are there underground or above ground storage tanks on premises? ___ Yes ___ No

Is there any storage of flammables, chemicals or fuels? ___ Yes ___ No

If yes, please describe

_____________________________________________________________________________

_____________________________________________________________________________

Is there lead paint in the residence? ___ Yes ___ No

Is there chemical spraying on premises? ___ Yes ___ No

If yes, describe what is sprayed and whether the insured or contractor does the spraying.

_____________________________________________________________________________

Does the insured own, lease or rent additional residences? ___ Yes ___ No

If yes, build a separate questionnaire for each residence.

Does the insured own rental property? ___ Yes ___ No

If yes, build a questionnaire for rental property.