Homeowners Insurance Questionnaire – Jessica Rollins Full name of property owner* Date of birth of property owner MM slash DD slash YYYY Second Property Owner?* Yes No Full name of second property owner Date of birth of second property owner MM slash DD slash YYYY Property Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email* What type of property is this?*Single-familyMulti-familyCondoWill the property be owner occupied or rented?*Owner occupiedRentedIs there any type of business conducted on the property?* Yes No Have you or your spouse had any insurance claims or losses in the last 6 years?* Yes No Has there been a lapse in coverage?* Yes No Policy cancelled for any reason?* Yes No Is your property equipped with a fire or burglar alarm that automatically reports to a station?* Yes No Do you have any pets?* Yes No Is there a pool on the property?* N/A In-ground Above-ground Is there a trampoline on the property?* Yes No When were the most recent updates (year) to your home and was it a full or partial update?Plumbing Heating Electrical Roof Are there any other hazards that the insurance company should be aware of?(building under construction, asbestos, trampoline, bankruptcies, judgements against you, etc.)If you know it, please provide your current auto insurer (for available discounts) Current policy declaration pages (if available) Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 64 MB. Allowed file extensions - pdf, doc, docxPlease note that most insurance carriers will contact you about a home inspection after coverage is bound.