Homeowners Insurance Questionnaire
Note: If LLC, Estate or Trust, Named Insured 1 information is required
Please review ALL your answers for accuracy as many required drop-down options are pre-selected. Incorrect or placeholder answers will only lengthen the processing time.
Insured Information
Desired Effective Date *
|
|
/ |
|
/ |
|
Named Insured (1)
Named Insured (2)
Location Address
Mailing Address
State / Province *
Contact Info.
Date of Birth Named Insured (1) *
|
|
/ |
|
/ |
|
Date of Birth Named Insured (2)
|
|
/ |
|
/ |
|
Marital Status *
Current Insurance Information
Current Insurance in-force? *
Policy Expiration Date
|
|
/ |
|
/ |
|
Is above Policy being Cancelled by Current Carrier? *
If so, Reason & Cancellation Date? (If none type none) *
Claims/Property Losses in Last 5 Years? *
If Claims, Please list and explain
Does Allstate write the Auto Coverage? *
FEATURES of your Home
Year Purchased *
If Purchase Date chosen above is 2016 or later
Year built *
Is This Home Occupied *
#of Families *
# of bedrooms *
#of full bathrooms *
#of half bathrooms *
Construction Type *
If Attic, is it finished?
Roof *
Foundation *
If Basement, please choose
Heat Type *
If Oil, where is the tank?
Electrical *
# of Fireplaces *
Wood Burning Stove? *
Miles to Fire Department *
Distance to Hydrant *
Year Electric Updated *
Year Heat Updated *
Year Plumbing Updated *
Year Roof Updated *
Garage Type *
Pool Features *
Fire Extinguishers *
Central Station Burglar Alarm *
Central Station Fire Alarm *
If so, how are they operated?
If Pets, What Kind *
If Pets, How many *
If Pets, Bite history *
Valuable Items Requiring Special Coverage
Number Of Items
Agency/Agent Information
Additonal Information/Notes
IMPORTANT NOTICE
Please note that after your submission we will contact you with a price indication but it is ultimately up to the carrier to accept or reject each risk. All price indication are reliant upon the information you as the agent have provided to United Agency Alliance, L.L.C
Price indications will be subject to the carrier underwriting guidelines and final approval. The carriers may obtain various underwriting reports which may include but not limited to C.L.U.E., credit and/or carrier specific reports.
Any submissions made via this website do not constitute a binding agreement to a policy or coverages. Changes to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.
Per the terms of our online privacy policy we will not resell your information to any third-party.
|