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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

Required

LLC, Estate or Trust Name (if applicable)

Optional

Named Insured (1)

First Name

Required

Last Name

Required

Named Insured (2)

First Name

Optional

Last Name

Optional

Location Address

Street

Required

City

Required

State Of

Required

ZIP / Postal Code

Required

Mailing Address

Street

Required

City

Required

State / Province

Required

ZIP / Postal Code

Required

Contact Info.

Primary Phone Number

Required

Alternate Phone

Optional

E-Mail Address

Required

Date of Birth Named Insured (1)

Required

Date of Birth Named Insured (2)

Optional

Occupations Named Insured (1)

Required

Occupations Named Insured (2)

Optional

Marital Status

Required

Current Insurance Information

Current/Prior Insurance Carrier

Required

Current Insurance in-force?

Required

Policy Expiration Date

Optional

Is above Policy being Cancelled by Current Carrier?

Required

If so, Reason & Cancellation Date? (If none type none)

Required

Claims/Property Losses in Last 5 Years?

Required

If Claims, Please list and explain

Optional

Does Allstate write the Auto Coverage?

Required

FEATURES of your Home

Year Purchased

Required

If Purchase Date chosen above is 2016 or later

Please provide complete previous address or type N/A

Required

Year built

Required

Is This Home Occupied

Required

#of Families

Required

#of Stories

Required

# of bedrooms

Required

#of full bathrooms

Required

#of half bathrooms

Required

Square Footage

Required

Construction Type

Required

If EFIS, Year added

Optional

Crawl Space

Required

Attic

Required

If Attic, is it finished?

Optional

Roof

Required

Foundation

Required

If Basement, please choose

Optional

Heat Type

Required

If Oil, where is the tank?

Optional

Electrical

Required

# of Fireplaces

Required

Wood Burning Stove?

Required

Miles to Fire Department

Required

Distance to Hydrant

Required

Year Electric Updated

Required

Year Heat Updated

Required

Year Plumbing Updated

Required

Year Roof Updated

Required

Garage Type

Required

Garage # of cars

Optional

Deck

Required

Deck Square Footage

Optional

Pool

Required

Pool Features

Required

Trampoline

Required

Smoke Detectors

Required

Dead Bolts

Required

Fire Extinguishers

Required

Central Station Burglar Alarm

Required

Central Station Fire Alarm

Required

Sump pumps?

Required

If so, how are they operated?

Optional

Pets

Required

If Pets, What Kind

Required

If Pets, How many

Required

If Pets, Breed

Optional

If Pets, Bite history

Required

Valuable Items Requiring Special Coverage

Number Of Items

Optional

Total Value

Optional

Agency/Agent Information

Agency Name

Required

Agency Number

Required

Agent Email Address

Required

Additonal Information/Notes

Optional

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.

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Headquarters

56 Payne Road
Lebanon, NJ 08833
P: 973.526.7038