Acme Inc.

Home Insurance Coverage Assessment

  1. Instructions

    1. Instructions

  2. Basic Information

    1. *Full Name

    2. *Date of Birth

    3. Email Address

    4. Phone Number

    5. Occupation

    6. Social Security Number (Optional)

  3. Property Information

    1. *Residential Address

    2. *Property Type

    3. *Year Built

    4. *Construction Type

    5. *Square Footage

    6. *Number of Stories

    7. *Roof Type

    8. *Roof Age

    9. *Foundation Type

    10. *Is the property in a flood-prone area?

    11. *Does the property have any of the following?

  4. Occupancy and Usage

    1. *Is this the primary residence?

    2. *Is the home used for any business purposes?

    3. *Is the home rented to tenants or others?

    4. *Do you have any pets?

    5. *How many people live in the home?

  5. Coverage Details

    1. Current Home Insurance Provider (if applicable)

    2. Policy Expiration Date

    3. Desired Start Date for New Coverage

    4. Coverage Types Requested

  6. Property Features and Safety Measures

    1. *Heating System (Gas, Electric, Oil, Solar, etc.)

    2. *Cooling System (Central AC, Window AC, None, etc.)

    3. *Does the property have updated electrical wiring?

    4. *Does the property have updated plumbing?

    5. *Is the property equipped with a fire suppression system?

    6. *Is the property located near a fire hydrant or fire station?

    7. *Has the property undergone any renovations or upgrades?

  7. Claim History

    1. *Have you ever filed a home insurance claim in the past 5 years?

    2. If you have filed a home insurance claim in the past 5 years, please provide details of:

    3. Have you had any insurance coverage canceled or non-renewed in the past?

  8. Discount Eligibility

    1. *Do you have any other policies with us (auto, life, etc.)?

    2. *Are there any security features in the home?

    3. *Are you retired?

    4. *Are you a non-smoker?

    5. *Do you have a good credit score?

  9. Additional Coverage Options

    1. *Flood Insurance

    2. *Earthquake Insurance

    3. *Jewelry or Valuable Item Insurance

    4. *Home Business Insurance

    5. *Umbrella Policy

    6. *Is the property owned by a trust?

    7. Is there anything else you'd like us to know about your home or insurance needs?

    8. Do you have specific concerns about your coverage?

Home Insurance Coverage Assessment


Home Insurance Coverage Assessment

Acme Inc.



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    Thank you for taking the time out to fill this questionnaire. This assess risk, coverage needs, and potential discounts for home insurance.



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    *Response requiredFull Name

    *Response requiredDate of Birth

    Phone Number

    +31

    Occupation

    Social Security Number (Optional)

    Optional, for background/credit check

    *Response requiredResidential Address

    Please include property number, street, city, state, and zip code.

    *Response requiredProperty Type

    • Single-family home

    • Multi-family home (e.g., duplex)

    • Condominium

    • Townhouse

    • Mobile home

    *Response requiredYear Built

    *Response requiredConstruction Type

    • Wood Frame

    • Brick

    • Stone

    • Stucco

    *Response requiredSquare Footage

    *Response requiredNumber of Stories

    *Response requiredRoof Type

    Shingle, Metal, Tile, etc.

    *Response requiredRoof Age

    *Response requiredFoundation Type

    Slab, Basement, Crawlspace, etc.

    *Response requiredIs the property in a flood-prone area?

    • Yes

    • No

    *Response requiredDoes the property have any of the following?

    • Swimming pool

    • Garage

    • Security system

    • Smoke detectors

    • Fire extinguishers

    *Response requiredIs this the primary residence?

    • Yes

    • No

    *Response requiredIs the home used for any business purposes?

    • Yes

    • No

    *Response requiredIs the home rented to tenants or others?

    • Yes

    • No

    *Response requiredDo you have any pets?

    • Yes

    • No

    *Response requiredHow many people live in the home?

    Current Home Insurance Provider (if applicable)

    Policy Expiration Date

    Desired Start Date for New Coverage

    Coverage Types Requested

    • Dwelling Protection (Home structure coverage)

    • Personal Property Protection (Furniture, appliances, electronics, etc.)

    • Liability Protection (Injury or property damage claims)

    • Medical Payments to Others (Injuries sustained on your property)

    • Additional Living Expenses (In case you need to live elsewhere due to damage)

    *Response requiredHeating System (Gas, Electric, Oil, Solar, etc.)

    What type of fuel heats your home?

    *Response requiredCooling System (Central AC, Window AC, None, etc.)

    *Response requiredDoes the property have updated electrical wiring?

    • Yes

    • No

    *Response requiredDoes the property have updated plumbing?

    • Yes

    • No

    *Response requiredIs the property equipped with a fire suppression system?

    • Yes

    • No

    *Response requiredIs the property located near a fire hydrant or fire station?

    • Yes

    • No

    *Response requiredHas the property undergone any renovations or upgrades?

    • Yes

    • No

    *Response requiredHave you ever filed a home insurance claim in the past 5 years?

    • Yes

    • No

    If you have filed a home insurance claim in the past 5 years, please provide details of:

    Have you had any insurance coverage canceled or non-renewed in the past?

    If Yes, please explain the reason.

    *Response requiredDo you have any other policies with us (auto, life, etc.)?

    • Yes

    • No

    *Response requiredAre there any security features in the home?

    • Security Cameras

    • Deadbolt Locks

    • Motion Detectors

    • Gated Community

    *Response requiredAre you retired?

    • Yes

    • No

    *Response requiredAre you a non-smoker?

    • Yes

    • No

    *Response requiredDo you have a good credit score?

    • Yes

    • No

    *Response requiredFlood Insurance

    • Yes

    • No

    *Response requiredEarthquake Insurance

    • Yes

    • No

    *Response requiredJewelry or Valuable Item Insurance

    • Yes

    • No

    *Response requiredHome Business Insurance

    • Yes

    • No

    *Response requiredUmbrella Policy

    • Yes

    • No

    *Response requiredIs the property owned by a trust?

    • Yes

    • No

    Is there anything else you'd like us to know about your home or insurance needs?

    Do you have specific concerns about your coverage?

    If Yes, please describe.