Homeowner Survey 1. Is there any real estate owned in addition to insured dwelling? * Yes No 2. Have you remodeled or made significant changes to your home? * Yes No 3. Do you have any "appurtenant structures" (garage, etc.) on insured premises? * Yes No 4a. If 'Yes' on question 3, any used for business purposes? Yes No 4b. If 'Yes' on question 3, any rented to others? Yes No 5a. Do you have a swimming pool? * Yes No 5b. If 'Yes', please select: In Ground Above Ground 6. Do you have personal property totaling more than the policy automatically provides? * Yes No 7. Do you have any jewelry, furs, guns, cameras, or collectibles? * Yes No 8. Do you have exposure to water that backs up through sewers or drains? * Yes No 9. Do you desire to carry earthquake coverage? * Yes No 10. Do you have a wood burning stove, kerosene heater, etc.? * Yes No 11. Do you have any questions regarding flood coverage? * Yes No 12. Do you have any incidental business activities our of your home? (Baby-sitting, Amway, Beauty Shop, Newspaper Delivery or Lawn Care) * Yes No 13a. Do you own any pets? (Kind, Breed and How Many) * Yes No 13b. If 'Yes', Kind / Breed / Qty 14. If we currently have your home and auto policy, would you be interested in a $1,000,000 liability policy? * Yes No 15. Do you have any recreational vehicles? (Boat, Motorcycle, Moped, 3-wheeler or snowmobile) * Yes No 16. Do you serve as an officer or member of the Board of Directors of a non-profit corporation or organization? * Yes No 17. Are you interested in saving money on your homeowner’s insurance if we can write your auto? * Yes No 18a. Do you have any problems, questions or concerns? * Yes No 18b. If 'Yes', please describe: 19. Are you interested in identity theft coverage? * Yes No Name: * Policy #: Phone #: * Email Address: * Date * reCAPTCHA If you are human, leave this field blank.
