Midwest Certified Insurance Agency, Ltd.
Homeowner Questionnaire
If Insured’s dec pages have been obtained, you only need to complete the bolded questions.
Today’s Date: ______Producer Name: ______
Effective Date: ______Producer Phone: ______
Insured/Co-Applicant Name(s):______
(Insured Names must be the same as the deed of the home)
Street Address: ______City: ______
County: ______State: ______Zip: ______Phone:______
Marital Status: ______
Insured Date of Birth: ______/ Co-Applicant Date of Birth:______
Insured SS #: ______/ Co-Applicant SS #:______
Insured Occupation(s): ______/ Co-Applicant Occupation: ______
Highest Education (circle): High School / Associates Degree / Bachelor’s Degree / Law or Medical Degree
Is Insured an AARP member? _____ Yes _____ No If yes, provide Member ID#:______
If at current address less than 1 years, please provide insured’s previous address:
Street: ______City: ______
County: ______State: ______Zip: ______Phone: ______
Amount to be quoted on Dwelling:______(100% replacement cost) Deductible:______
Liability Limit: ______Medical Payments: ______
Schedule Jewelry/Furs/Fine Arts Etc. Amount: ______(provide description & value of each item)
Water Back-up Limit (amount): ______Sump Pump? ______Yes ______No
Back-up sump pump system available? ______Yes ______No
Identify back-up system: (circle one) Gas Powered / Water Powered / Battery Powered/ Whole House Generator
Year Built: ______Purchase Date: ______Purchase Price: ______Square Footage: ______
Architecture Style: (Circle) Ranch/Split Level/Colonial/Other: ______# of Stories: ______
# of Bath Rooms:______Garage: (Circle) Attached/Detached Garage Size: (Circle) 1car/2car/3car
Deck:______sq ft. Porch (open/enclosed/screened): ______sq ft.
Page 1 of 2
Homeowner Questionnaire
CIRCLE ALL THAT APPLY:
Number of Families: One / Two / Three / Four
Exterior Construction: Frame / Aluminum/Vinyl Siding / Masonry / Masonry Veneer / Stucco
Foundation Type: Slab / Crawlspace / Basement (unfinished) / Basement (finished)
Roof Type: Asphalt Shingle / Architectural Shingle / Tile or Slate / Wood Shingle / Tar & Gravel
Heat Type: Gas / Radiator / Other:______
Additional Features: Central HVAC / Wood Stove / Fireplace #______Hot Tub / Trampoline: Open / Enclosed
Fenced Yard: Height of fence ______ft / Swimming Pool: Above ground / In ground / Slide / Diving Board
Business in Home? If yes provide details: ______
# of dogs on premises ______Breed of each dog:______
Does the Home have (Circle):
Monitored Fire/Burglar Alarm (must provide alarm certificate)
Fire Extinguisher(s)Dead BoltSmoke Alarms
Is Property currently: For sale? Yes / NoIn Foreclosure: Yes / No
IF HOME IS MORE THAN 15 YEARS, YOU MUST PROVIDE THE YEAR THE UTILITIES WERE UPDATED:
Furnace ______Electrical ______Plumbing ______Roof ______
Electrical System: Circuit Breakers or Fuses (circle one)
Any Homeowner claims in past 5 years? Yes / No
If yes, provide details (date/type of loss/amount paid):______
______
Current Mortgage Company: ______
Current Carrier: ______# of Years w/carrier: ______
Expiration Date: ______Premium: ______
Has coverage been cancelled or non-renewed in last 3 years? Yes / No
If yes, provide reason: ______
Additional information: ______
______
Page 2 of 2 (Revised 04/2016)