Insurance Noodle – Personal Home and Auto Questionnaire:
Contact Info
Agency Producer:
Agency Customer Service Rep:
Please Fill In The Profile Information
Note: The fields below should reflect the BILLING information. Required questions are indicated with *
First Name:*
Middle Initial:
Last Name:*
Street Address:*
Floor/Suite Number:
City:*
State:*
Zip Code: 29681
Phone Number:*
(Enter 10 digits only)
Fax Number:
(Enter 10 digits only)
Eligibility Questions
Named Insured licensed driver more than five (5) years? Yes No
All drivers held valid US or Canadian license for past 12 months (excluding new drivers under 18)? Yes No
Any fire losses in the past three (3) years? Yes No
One (1) major violation or more than five (5) incidents per policy in last five (5) years? Yes No
Any vandalism losses in the past three (3) years? Yes No
One (1) major violation or more than four (4) incidents per driver in last five (5) years? Yes No
Any liability losses in the past three (3) years? Yes No
Theft losses in last three (3) years?
Any theft/burglary losses in the past three (3) years? Yes No
Any water damage losses in the past three (3) years? Yes No
More than three (3) comprehensive towing claims in last five (5) years, with more than $1,000 total paid out? Yes No
Wish to insure any of the following:
AC all, Acura NSX, Aston Martin, Avanti, Bentley, Bricklin, Cobra, DeLorean, DeTomasso, Dodge Viper, Excalibur, Ferrari, Hummer, Jenson Interceptor, Lamborghini, Lancia Scorpion, Lotus, Maserati, Morton, Panoz, Pantera, Pininfarina, Plymouth Prowler, Quavale, Rolls Royce, Subaru Brat, Suzuki Samauri or Sidekick, TVR, Vector, Yugo or any exotic cars, kit cars, vehicles modified for performance or racing, any customized vehicle or vehicle changed to be one-of-a-kind, any vehicle with modified suspension, any replica model, any vehicle with a plastic/aluminum/stainless steel body, or any ATV/dune buggies/vehicles used for off-road? Yes No
Home occupied by more than two (2) families? Yes No
Roof been updated within the past 25 years?
Any bus or vehicle used as primary residence (i.e., motorhome)? Yes No
Any passenger vehicles worth more than $150,000 or motorhomes worth more than $200,000? Yes No
Standard continuous auto coverage for the last 12 months?
If value of jewelry is higher than $100,000, does the house have a central alarm system?
Spouse insured on separate auto policy?
If there is a woodstove, was it installed by professionals and according to code?
If there is a woodstove, is it the primary source of heat for the home?
If there is a woodstove, is home located within 5 miles of a fire station?
Has any operator been convicted
of a crime resulting from the use
of a motor vehicle or been convicted
of theft of a motor vehicle? Yes No
Has any operator been convicted
of fraud or intent to defraud
involving an insurance claim or
application for insurance? Yes No
Home a log home built prior to 1980? Yes No
Home constructed with asbestos building materials (including roof materials) or knob tube or aluminum wiring? Yes No
Has any operator been denied
payment of a claim in excess of
$1,000 under an auto policy due to
fraud/intent to defraud involving a
claim/application? Yes No
Home exposed to any known brush, range or forest fire, or within the susceptible path of an existing fire or location exposed to brush or forest fire? Yes No
Has any operator knowingly provided
materially false/misleading
information in connection with an
application/renewal/claim under an
insurance policy? Yes No
Any insured drivers hold a primary license in any country outside the US? Yes No
Home exposed to any wave crash, cave in, sink hole or landslide loss exposure? Yes No
Any insured drivers have financial responsibility for an uninsured accident (SR-22)? Yes No
If "Yes" response to any of the following questions application will be referred to a Surplus Lines carrier.
Please note that it is the responsibility of the agent to notify the client that the policy is being written through a Surplus Lines carrier.
Any insured drivers have suspended or revoked licenses? Yes No
Any drivers with less than three (3) years driving experience slated to be principal driver of a private passenger vehicle 30 feet or longer? Yes No
Value of residence must be at least $300,000 to qualify for the Surplus Lines program.
Any vehicle to be used for delivery, hire, taxi, emergency response, used in business by a tradesman, artisan, wholesaler, or retailer? Yes No
Is the dwelling vacant? Yes No
Has there been more than one (1) property loss in the past three (3) years (including catastrophic losses)? Yes No
In last 12 months, moved to current state of residence and failed to secure a new driver's license for that state? Yes No
House in course of construction? Yes No
Any vehicles previously totaled, salvaged, restored, or reconstructed? Yes No
Any drivers with conditions or medication which impairs driving ability? Yes No
Home a mobile home? Yes No
Are there any open foundations, piers, stilts or pilings? Yes No
Any vicious or aggressive pets, including, but not limited to Pit Bulls, Rottweilers, Presa Canario breeds? Yes No
Any animals with a bite history? Yes No
Any underground fuel tanks or unfenced swimming pools? Yes No
Ever convicted of vehicular homicide? Yes No
House up for sale? Yes No
General Information
Been at current address less than six (6) months? Yes No
Select the Named Insured's credit score:
Number of years at current address:
Within 250 feet of a commercial or non-residential property? Yes No
Social Security Number:
(Note: Required to provide an accurate price and to issue/bind a policy.)
Garaging address residence type:
Date of birth:
Insured's occupation and type of business/industry:
(For example, salesperson for a transportation company.)
Marital status:
Spouse's name:
Insurance policy been cancelled, lapsed or non-renewed within the past (5) Years? Yes No
Effective date policy cancelled, lapsed, or non-renewed:
Name of insurance carrier issuing cancellation, lapse or non-renewal:
Policy limits on cancelled, lapsed, or non-renewed policy:
Any insurers you would not like a quote from? Yes No
Insurer names:
Spouse's Social Security Number:
Spouse's date of birth:
Spouse's occupation and type of business/industry:
(For example, salesperson for a transportation company.)