Personal Lines Update Questionnaire
Policy Number: Named Insured:
Policy Effective Date: Agent’s Name:
Address:
Today’s Date:
Phone Number:
Advisory: The Purpose of this Questionnaire is to determine compliance with our Underwriting Guidelines.
Please Review & Advise your Agent of any Changes you wish to make to this policy.
Current Coverages Are As Follows:
Dwelling:
Other Structures:
Contents:
Liability:
Deductible:
Insured’s Occupations: (1) (2)
Location of Occupations: (1) (2)
1. How many families reside in the dwelling? How many residents?
2. What is the current occupancy type? Owner Tenant Both Vacant Seasonal
3. If the dwelling is tenant occupied:
Is there a formal Lease Agreement? Yes No
Are the tenants allowed Pets / Animals? Yes No
If yes, please explain
Who is responsible for Property Maintenance (incl. Snow Removal)? Tenant Owner
Property is managed by
4. Are any Fire/Burglar/Sprinkler/Smoke Devices installed? Yes No
If yes, please describe type of installation
5. Are annual checks performed on existing Smoke Detectors?
6. Is the dwelling occupied daily? Yes No
7. Whate is the Primary Heat Source?
Please indicate other Heat Sources that may be used:
8. Have there been any Updates / Renovations or Square Footage added to the dwelling? Yes No
If yes, what was done and when?
Including: Wiring
Plumbing
Heating
Roofing
9. How many feet from the dwelling to a Fire Hydrant? ft.
10. How many miles from the dwelling to a Fire Station? mile(s)
11. Is there a Trampoline on premises? Yes No
12. Is there a Swimming Pool on premises? Yes No
13. Is the dwelling up for Sale? Yes No
14. Is there any Farming conduction on premises? Yes No
If yes, please explain
15. Do you operate a Business on premises? Yes No
If yes, please explain
16. Do you have any Residence Employees? Yes No
17. Do you own Recreational Vehicles? (Boats, ATVs) Yes No
If yes, please list each vehicle:
18. Are there any other residences that you own, occupy, or rent? Yes No
If yes, please list each:
Address / Policy Number / Use of Premises19. Do you own any Pets/Animals or plan to acquire any Pets/Animals.
If yes, please list each:
Pet/Animal / Breed / Bite History (if any)20. Is this property within 300 feet of a Commercial or non-residential property? Yes No
If yes, please explain
22. Has any Insured had foreclosure, repossession, or bankruptcy, in the last 5 years? Yes No
If yes, please explain
23. Is this dwelling Vacany or Unoccupied for more than 30 days a year? Yes No
If yes, please explain
I have read the above questionnaire and I declare that to the best of my knowledge and belief all of the foregoing statements are true, complete, and correct.
Please sign & attach current photos of the dwelling & woodstove (if applicable) –Thank You!
Signature Date:
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