Required Homeowners Questionnaire

Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me. Please note that coverage cannot be bound or changed by using the Internet or Email.

Insured Name (spouse)
Address
City, State, Zip, County
Out of state information
Home Phone / Cell Phone
Email address
Social Security Number
Social Security Number (spouse)
Date of Birth (mm/dd/yyyy)
Date of Birth (spouse)

Homeowner Limits

Current Carrier
Expiration date (mm/dd/yyyy)
Location Address if different
Dwelling Replacement Value:
(if) Condo: # of stories
(if) Condo: # of Units
(if) Condo: dwelling
(if) Condo: contents
Year Built
Square Footage
Construction
# of Stories
Roof Material
Roof Type
Swimming Pool:
 Yes
 No
________________________________________
Screened
 Yes
 No
________________________________________
Diving Board
 Yes
 No
________________________________________
Must have if over ten years old:
Updates: Wiring
 Yes
 No
Date wiring updated (if applicable)
Updates: Roof
 Yes
 No
Date roof updated (if applicable)
Updates: Plumbing
 Yes
 No
Date plumbing updated (if applicable)
Garage
Smoke Detectors
 Yes
 No
Burgler / Fire alarm
 Yes
 No
Distance to Fire Hydrant (in feet)
Distance to Fire Station (in miles)
________________________________________
***Any losses in last 5 years
 Yes
 No
If yes, how much and when
________________________________________
***Any Pets
 Yes
 No
Breed
________________________________________
Flood Zone
 Yes
 No
________________________________________
Elevation Certificate
 Yes
 No
________________________________________
Owner Occupied
 Yes
 No
________________________________________
Seasonally Occupied
 Yes
 No
________________________________________
Gated Community
 Yes
 No

Before submitting this form, please click on the link below to move the contents of box "A" into box "B" leaving the first box empty.

A: B: Click to Move


 

Gifford-Heiden Personal InsuranceGifford-Heiden Personal InsuranceGifford-Heiden Personal Insurance
Gifford-Heiden Insurance

Gifford-Heiden Insurance Agency
111 East Venice Avenue
Venice, Florida 34285
Phone: (941) 484-0681
Phone:(941) 366-0500
Fax: (941) 485-3835
Email: ghi@giffordheidenins.com
Office Hours: Mon-Fri 8:30am-5:00pm

footer
Empowered by
Accrisoft Freedom