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)

NAME	AGE	RELATIONSHIP TO INSURED	OCCUPATION
_________________	_________________	_________________	_________________
_________________	_________________	_________________	_________________
_________________	_________________	_________________	_________________
_________________	_________________	_________________	_________________
_________________	_________________	_________________	_________________

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.

NAME	ADDRESS	RELATIONSHIP TO INSURED
_________________	_________________________________	_________________
_________________	_________________________________	_________________
_________________	_________________________________	_________________
_________________	_________________________________	_________________
_________________	_________________________________	_________________

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.