J Parisi Associates, Inc. - Personal & Business Insurance
 
Homeowners Insurance Questionaire
 
 
PROPERTY OWNER OR BUYER INFORMATION
OWNER'S NAME
DATE OF BIRTH
CO-OWNER'S NAME
CO-OWNER'S DATE OF BIRTH
PROPERTY LOCATION ADDRESS
CURRENT MAILING ADDRESS
IS THIS HOUSE BEING PURCHASED OR BEEN PURCHASED WITHIN THE PAST 12 MONTHS?
TYPE OF CONSTRUCTION
NUMBER OF STORIES
USE OF HOME
YEAR OF CONSTRUCTION
SQUARE FOOTAGE OF HOUSE
BUILDING COVERAGE AMOUNT DESIRED (IF KNOWN)
PERSONAL LIABILITY LIMIT
DEDUCTIBLE DESIRED
ADDITIONAL OPTIONS AVAILABLE
CHOOSE ANY ADDITIONAL OPTIONS YOU WISH TO ADD TO QUOTE
WATER BACK-UP
IDENTITY THEFT
EARTHQUAKE
PERSONAL INJURY (LIBAL/SLANDER)
CHILD CARE IN HOME LIABILITY
DISCOUNTS AVAILABLE

SMOKE ALARM, DEADBOLTS, OR FIRE ESTINGUISHER
CENTRAL STATION ALARM SYSTEM
BOTH: CENTRAL STATION ALARM & SMOKE ALARM ETC.
RENOVATION DISCOUNT: PLEASE INDICATE IF YOU HAVE REPLACED ONE OR MORE OF THE FOLLOWING IN THE MOST RECENT FIVE YEARS.

NONE
ROOF
FURNACE, HOT WATER HEATER, OR A/C
ELECTRIC
PLUMBING
ANY ADDITIONAL INFO THAT YOU FEEL IS IMPORTANT:
YOUR E-MAIL ADDRESS
DAY TIME PHONE NUMBER
THANK YOU FOR CONSIDERING US FOR YOUR INSURANCE!
 
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