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Applicant Information
Primary Residence
| Rooms Etc |
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No. of Stories |
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No. of Rooms |
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No. of Bedrooms |
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No. of Baths |
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No. of Garages |
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No. of Pools |
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No. of Guest Houses |
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No. of Athletic Courts |
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No. of Exercise Rooms |
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No. of Basements |
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No. of Other Bldgs |
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| Details |
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Is home in your name or a trust of some form? |
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Do you rent out your home when not using it? | |
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Is home within city limits? |
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Is home located on more than 5 acres? |
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Have you lived in home more than 3 years? |
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Is home mortgaged? |
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Is home located in a gated community? |
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Is home privately gated itself? |
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Does home have fire & theft alarm? |
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Does security system include cameras? |
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Do you have on-site security guards? |
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Does home have under roof fire sprinkler? |
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Is home undergoing renovation or building? |
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Do you own any other homes or residences? |
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Does your pool have a diving board or slide? |
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Do you own any exotic pets or animals? |
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Do you have a trampoline? |
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Do you operate a business from home? |
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Do you need a flood quote included? |
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Do you need an earthquake quote included? |
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| Question/Comment/Additional Information:
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Guest Home
| Guest Home |
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No. of Stories |
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No. of Rooms | |
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No. of Bedrooms |
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No. of Baths | |
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No. of Garages |
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| Age, Size, Renovations, Occupants |
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| Question/Comment/Additional Information:
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Vacation Home
| Rooms Etc |
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No. of Stories |
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No. of Rooms |
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No. of Bedrooms |
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No. of Baths |
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No. of Garages |
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No. of Pools |
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No. of Guest Houses |
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No. of Athletic Courts |
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No. of Exercise Rooms |
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No. of Basements |
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No. of Other Bldgs |
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| Age, Size, Renovations |
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| Question/Comment/Additional Information:
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Autos
| Previous address (If less than 3 at current) |
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| Drivers |
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Do you own any vehicles or car collections that are
not garaged at your home addrss?
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Any driver in household not listed on application ? |
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Do any drivers live away from home (ie. college students)? |
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Do any vehicles have any damage (ie. glass damage)? |
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Do any vehicles have special modifications? |
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does any driver have special credits that may apply to them? |
*** we will call you for social security number for prior claims
*** we will call you for further details of your classic autos when necessary
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| Question/Comment/Additional Information:
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Jewelry
| Jewelry and Collections |
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Is jewelry over $50,000 in value kept in safety deposit box not at home? |
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Is jewelry typically kept in safe or vault at home? |
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Do you use your golf equipment during travel? |
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Do you own special cameras or photography equipment? |
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Do you own specially valued musical instruments? |
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Do you own specially valued silverware or dinnerware? |
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Do you own specially valued stamps or coin collections? |
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Do you own specially valued guns or rifles? |
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Do you own household paintings or art to be scheduled? |
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Do you keep diamonds or loose precious stones at home? |
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Do you keep silver or gold bullion, coints or bars at home? |
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Do you typtcally keep more than $20,000 in the safe at home? |
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Have you had any personal property claims in the last 3 years? |
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Do you own anything else of value that might need to be listed? |
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| Collection Details |
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| Question/Comment/Additional Information:
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Aircraft
| Pilot Information |
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| Question/Comment/Additional Information:
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Watercraft
| Misc |
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Docking?
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Do you employ a paid captain or crew? |
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Is the boat chartered to others? |
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Is the boat used for racing? |
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Has your insurance ever been cancelled or non-renewed? |
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| Question/Comment/Additional Information:
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Collections
| Collections |
Due to the large scope of this policy and what it can cover . we
have found it easier to gather a short description of the types of
collections that our clients would like to cover and then gather the
additional infomrmation over the phone or in person. Accordingly,
please enter a short description of the number of collections and a quick
description of each so that we may have enough infomormation
to customize our interview with you.
Enter collection info here:
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Umbrella Coverage
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