homeowners insurance data sheet

homeowners insurance data sheet
HOMEOWNERS INSURANCE DATA SHEET
Date: ___________________
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Name: ________________________________________________________
Referred by: [ ] internet
[ ] print advertisement
[ ] friend / family ____________________________________________________
[ ] professional recommendation _______________________________________
Property Address:
Mailing Address:
Best Contact Number: [ ] cell [ ] home [ ] business
Email Address:
Move in Date:
Closing Date:
Previous Pending Claims? [ ] yes
[ ] no
Will you operate a business on the premises?
Any judgements, bankruptcy or foreclosures in past 5 years?
[ ] yes
[ ] no
INSURED #1
Date of Birth
Occupation/Company Name
Social Security Number
INSURED #2
Date of Birth
Occupation/ Company Name
Social Security Number
Year Built:
Owner or Tenant Occupied?
# of stories
# of families
Construction:
[ ] brick
[ ] frame
Sidewalk condition:
[ ] poor
[ ] excellent
Purchase Price:
[ ] good
Purchase Date:
Roof:
[ ] peaked
Pets:
[ ] no
[ ] flat
[ ] yes _________________________
Mortgage Amount:
Central Station Alarm:
[ ] yes
[ ] no
Smoke Detectors:
Fire Extinguishers
[ ] yes
[ ] no
Feet to Nearest Hydrant:
Miles from Nearest Fire Station:
Upgrades (list year)
Heating
Plumbing
Electric
Roof
Other
705 Ridge Road
Lyndhurst, NJ 07071
201-933-3333
[ ] yes
[ ] no
Is Extra Coverage Needed?
[ ] yes [ ] no
Jewelry
[ ] yes [ ] no
Furs
[ ] yes [ ] no
Silver
[ ] yes [ ] no
Electronics
[ ] yes [ ] no
Other
235 Bloomfield Ave.
Bloomfield, NJ 07003
973-566-6666
Email us at: [email protected]
9 Frank E Rodgers Blvd. S
Harrison, NJ 07029
973-350-9999
HOMEOWNERS INSURANCE DATA SHEET
Distance to Neighboring Buildings (in feet)
[
] Left side
[
] Right side
Living Space Square Footage: _____________
Heating/Cooling: [ ] natural gas [ ] oil
[ ] propane
[ ] central air (same duct) [ ] central air (separate duct)
[ ] one unit heating and cooling
[ ] window A/C
[ ] roof A/C unit
[ ] house fan
Style Home
[ ] Ranch
[ ] Cape Cod
[ ] Bi Level [ ] Raised Ranch
Type of Siding
[ ] Concrete
[ ] Solid Brick
[ ] Adobe
Roofing Material
[ ] Slate
Basement:
[ ] yes
[
[
[
[ ] no
Oil tank location: ________________________________
Tank test? [ ] yes [ ] no
Soil test? [ ] yes [ ] no
[ ] Colonial
[ ] Victorian
[ ] Contemporary [ ] TownHome
] Aluminum
] Brick Veneer
] Stucco
[ ] Tile
[ ] electric
[ ] Vinyl
[ ] Wood
[ ] Solid Stone
[ ] Stucco on Masonry
[ ] Wood Shakes
[ ] Split Level
[ ] Tri Level
[ ] TownHome (end unit)
[
[
[
] Wood Shakes
[
] Stone Veneer
[
] Stucco on Frame
[ ] Composition Shingle
[ ] Asbestos Shingle
] Log
] Asbestos Shingle
[ ] Tin
What % of your basement is finished?
Mortgage Company Name:
List the Number of Each
[
] Kitchen
[
] Breakfast Nook
[
] Dining Room
[
] Living Room
[
] Den/Study
[
] Bedroom (10x12)
[
] Bedroom (12x12)
[
] Bedroom (15x15)
[
] Walk in Closets
[
] Entry Foyer
[
] Bathroom (full)
[
] Bathroom (half)
[ ] Family Room
[
] Laundry Room
[
] Mud Room
[
] Sun Room
[
] Utility Room
[
] Fireplace
[
] Other _______________
[
] Finished Attic
[
] Deck _______sq
[
] Patio ________sq.
[
] Trampoline
[
] Open Porch
[
] Enclosed Porch
[
] Built in Garage
[
] Attached Garage
[
] Detached Garage
[
] # of Vehicles
[
] Carport
[
[
] Shed (large)
] Shed (small)
Pool:
[ ] Above ground
[ ] In ground concrete)
[ ] Diving Board
Interior Walls - % that are:
drywall _____ sheetrock _____ plaster _____
Ceilings - % that are:
drywall _____ sheetrock _____ plaster _____
Flooring - % that are:
ceramic tile _____ imported tile/marble _____ vinyl/linoleum _____
hardwood _____ parquet _____
wall to wall carpet _____ wall to wall carpet over hardwood _____
[ ] Range Hood
(vented to outside)
[ ] Central Vacuum
Special Features – Mark All that Your Home Contains
[ ] Ceramic
[ ] Marble Countertop [ ] Wet Bar
Countertop
[ ] Hardwired Audio
[ ] Spiral Staircase
[ ] Stained Glass
Speakers
[ ] Fenced In
[ ] Large Kitchen
Cabinets
[ ] French Doors
[ ] Sliding Glass Doors
[ ] Ceiling Fan
[ ] Bay Window
[ ] Bow Window
[ ] Atrium Window
[ ] Intercom System
[ ] Sump Pump
[ ] Exterior Shutters
[ ] Sauna
[ ] Hot Tub
[ ] Jacuzzi
[ ] Burglar Alarm
[ ] Fire Alarm
[ ] Fire Sprinkler
System
[ ] Skylight (small)
[ ] Skylight (large)
Email us at: [email protected]
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