What are your legal names?
- What is the address of the property?
- Is your home under 40 years of age?
- What is the year of construction of your home?
- What bank holds the mortgage?
- What is the type of construction?
- Does a single family inhabit your home?
- Does your home have smoke detectors?
- Do you have a burglar alarm?
- Do you have a fire department fire alarm?
- Do you have automatic sprinklers?
- How many rooms in your home?
- Do you have a woodstove?
- Has your woodstove been inspected?
- Do you have a central heating system?
- How do you heat your home?
- Have you had any insurance losses in the last five years?
- Do you or any household member smoke?
- Do you desire a $250 or $100 deductible?
- Do you own a dog? What breed?
- Do you own a boat, trailer or camper?
- Do you live near a pond, river or large body of water?
- Are you in a flood zone?
- Is your home under construction or being remodeled?
- Do you have any boarders that are not family members?
- Do you have tenants?
- Do you furnish any belongings in the part of the premises you rent?
- Would you like replacement cost on your contents?
- Would you be interested in an inflation guard built into your policy?
- Do you want earthquake coverage?
- Do you have any children away at school
- Will your home be vacant more than 30 days?
- Do you own an aircraft?
- Do you or your family members have any belongings owned by others in your care custody or control
- Do you keep any belongings in any other residence owned by you?
- Do you rent any structure on your property?
- Do you use any structure on your property for business use?
- Do you own a personal computer? Is it used for business use?
- What is the estimated worth of your software?
Section I Coverages
- Do you or anyone in your household own a single item of jewelry, watches, furs, or precious or semiprecious stones worth more than $1,000?
- Does the total value of your jewelry, watches, furs or precious or semiprecious stones exceed $1,000?
- Do you own firearms worth over $2,000?
- Does the value of your silverware, silver-plated ware, gold-ware, gold-plated ware, or pewter, exceed $2,500?
- Do you keep any belongings in your home that are used in any manner for business use worth more than $2,500?
- Do you belong to any association of property owners responsible for something owned collectively?
- Do you have articles of value such as antiques, stamp or coin collections, fine arts, furs, golf equipment, musical instruments, silverware, china or the like, which you would like to insure on a scheduled per-item basis?
Section II Coverages
- Would you like a limit of liability higher than $100,000?
- Would you like a higher amount of coverage for medical payments than the $1,000 limit?
- Do you own any other residence?
- Do you rent the other residence?
- Do you conduct any farming on your premises?
- Is farming your principal occupation?
- Do you own a snowmobile?
- Would you like to be covered for libel, invasion of privacy or false arrest for an additional $13 a year?
- Would you be interested in a personal umbrella policy covering you for $1 million above and beyond the liability coverages you carry on your home and auto?
Signature of Applicant ______________________________ Date _________
Signature of Agent _________________________________ Date _________