Dwelling Fire Insurance Intake Questionnaire - Almeida and Carlson Insurance Agency

Greetings! In order to provide an accurate rating for a Dwelling insurance quote, please answer the following questions:

Named Insured(s)

Name/s (as shown on deed):(Required)

First

Last

Date of Birth:(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Location to be Insured

If the home is deeded to a Trust, please provide the name of the trust:

Trustee name(s):

First

Last

Beneficiary:

Please indicate if trustee and/or beneficiary resides at the property:

Years at insured location?

If less than 3, what is prior address?

Purchase Price?

Coverage Effective Date:

Preferred deductible ($500/1,000/2,500/etc)

Do you currently have a Homeowner policy? If not, why? (Nonpayment, underwriting, new home purchase?)

Is this a long or short term rental? How many weeks per year? (Explain):

Do you use a realtor or rental platform such as AirBnb, Vrbo, etc? (Describe):

Property Details

Primary, secondary, or rental home?

Type of home (single family, condo, mobile home, etc):

Is the home visible to neighbors?

Is the property located within 300 feet of a commercial building?

Year Built?

# of Stories?

Square Footage:

Basement Finished?

Construction? (frame, brick, etc):

Foundation? (Basement/Slab/Crawl Space/Piers/Stilts):

Exterior Walls? (Wood/Clap/Vinyl/Shingles):

Roof? (3‐tab asphalt, architectural, wood, slate, etc):

Bay/Bow/Specialty windows? How many?

French doors/sliding glass? How many?

Kitchen & Bath (How many & quality?): Basic / Builders Grade / Semi Custom / Custom / Designer

Kitchen(s):

Full Bath(s):

Half Bath(s):

¾ Bath(s):

Garage? (Attached/Detached? # of cars)

Deck? (sq ft):

Porch? (sq ft):

Detached Structures (Describe):

If the home is older than 20 years, when (or best estimate) was the last time the following were replaced/updated?

Roof? (what year & details – complete/partial?):

Heating System? (what year & details – complete/partial?):

Wiring? (what year & details – complete/partial?):

Plumbing? (what year & details – complete/partial?):

Do you have a centrally monitored alarm or a Smart alarm?

(Type ‐ burglar, fire, water, freeze etc?)

Heat type (electric, propane, oil, gas/hot air or hot water):

If oil/propane heatistank indoors or outdoors, and aboveground or buried?

Age of tank?

Underwriting Questions

Do you have a wood or coal stove? (Describe):

Any smokers in the household?:

Do you have a whole house generator?:

Do you have an automatic water shut off?:

Have you had any insurance claims in the past five years? (Please explain date of loss, what happened, if claim closed, and amount paid):

Is the house under construction/renovation? (Please provide details):

Any foreclosure, repossession, or bankruptcies in the past 5 yrs?:

Do you own a trampoline?:

Is there a fully enclosed safety net?:

Does the house have a pool?:

Is there a diving board/rocks or slide?:

Do you allow animals?:

If yes, tenant has what type/breed, name & age?:

Bite history/Aggression?

Are there any weapons in the home?:

Do you own or occupy any other property?:

What is your occupation?:

Is there any business conducted from home?:

Do customers come on the property?:

Do you have insurance for your business?:

Billing Questions

Is there a mortgage on the property?

If yes, how many?

Mortgagee 1:

Mortgagee 2:

Mortgagee 3:

Is premium paid by escrow or insured?

If insured, bill by mail or EFT?

Do you prefer policy documents and billing by US mail or email?:

How did you hear about this agency?:

If you were referred, will you please let us know by whom so we may thank them?:

*Please be sure to answer all applicable questionsto help ensure accurate rating. If you have a current policy and would provide us with a copy it will help expedite the quoting process. Thank you for choosing Almeida & Carlson Insurance Agency for your insurance needs!

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