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Homeowners Questionnaire
Have your producers use this questionnaire from Jack Fries to garner needed information from Homeowners prospects: HOMEOWNERS INSURANCE QUESTIONNAIRE Producer: ______________________________________ Date: ___________________ INSURED Name _____________________________ Phone __________________ Address _______________________________________________________ City ______________________ State _____ Zip ____________________ Occupation ____________________________________________________ PRESENT HOME Homeowners Carrier _________________ Exp. Date_____________ LIMITS Dwelling _________________ Year Built _____________ Brick or Frame Additional Structures _______________ Liab. ___________ Contents _________________________ Medical ________ Loss of Use _______________________ Deductible ______ Prior Claims _______________________ Premium _______ Credits - Alarm, etc.________________________________ Guaranteed Replacement: Home Contents Additions/Alterations 'All Risk' Contents Theft Ext. Sewer Backup Subsidence Earthquake Extended Liability Scheduled Items Limits: Jewelry Furs Fine Arts (Breakage) Silver Coins Stamps Guns Boats Computers ______ Photo Equipment COMMENTS Are your autos insured with the same company? ____________ Expiration Date: _______________ RECOMMENDED Dwelling _________ Company ____________________ ­ LIMITS Liability _________ Deductible ______________ Premium ___________ Guaranteed Replacement Home ____ Contents 'All Risk' Contents Sewer Backup ____ Other REPLACEMENT Number of families Year Built _________ Sq. Ft _________ COMPUTATION Brick Frame Garage Cars Brick Frame Attached Balcony Porch Deck Sq. Ft. # of Fireplaces ____ # of Chimneys Inside Outside # of Baths Full 1/2 Basement? Finished? Central Air? ___ Wiring: -- Year Update: _________ Heating Construction Type I, II, III, IV Plumbing: -- Year Update: _______ Roof: -- Year Update: ___________ Built-ins: Stove Refrigerator Dishwasher Washer Dryer Sauna Hot Tub Replacement value _______ Market Value __________

Dwelling Replacement Cost Form
DWELLING REPLACEMENT COST FORM   NAME: LOCATION ADDRESS: DATE: Table A Enter 1 for each unit (ie. three bedrooms=3) listed below: Living Room Unfinished Attic Bedrooms Unfinished Basement (see note below) Bathrooms (3 or more fixtures) Stone exterior Walls Kitchen Clay Tile or Slate Roof Dining Room Two-Car Attached or Built-in Garage Family or Recreation Room Three-Car Carport Den, Study, Office, or Misc. Rooms Den, Study, Office, or Misc. Rooms (Over 300 Sq. Ft.) Table B Enter 1 for each unit listed below: Dinette or Breakfast Nook Enclosed Porch Half Baths (2 or less fixtures) One-Car Attached or Built-in Garage Laundry Room with adjacent Half Bath One- or Two-Car Carport Brick Exterior Walls Large Rooms (200 to 300 Sq. Ft.) Central Air Conditioning Table C Enter 1 for each unit listed below: Foyer or Entrance Hall Large Deck (over 300 Sq. Ft.) Walk-in Closet or Dressing Room Concrete Tile Roof Work, Storage, or Laundry Room Fireplace Breezeway or Open Porch Additional Cars per Garage (over two) Note: For Finished & Partially Finished Basements: 1. Finished basements: count only the finished rooms. 2. Partially finished basements: if the total unit count of the finished area in the basement exceeds Additional Information: Year House Built Square Footage: Year of last updating on: Roof Wiring Plumbing Heating Heat Type: Woodstove (if yes, is it used often?) Large Detached Building Smoke Alarm Deadbolt Locks Non-Smoker Central Station Reporting Burglar Alarm Police Station Reporting Burglar Alarm Central Station Reporting Fire Alarm Fire Department Reporting Fire Alarm Automatic Sprinkler System Central Vacuum System Domestic Solar Hot Water Heater Hot Tub Sauna Balconies (if yes, approximate size) Decks (if yes, approximate size) Swimming Pool (if yes, is it fenced in?) Electronic Garage Door Opener (how many) Wet Bar Air Conditioning (Central or through the wall unit(s) - how many) Skylights (if yes, how many) Trash Compactor Whole House Fan Countertop Range Intercom System Garbage Disposal&l

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