1501 Westcliff Dr. Suite 301
Newport Beach, CA. 92660
Tel: 877-700- NEWS
Fax: 949-554-0250
Email: Info@newsinsurance.com
Web: www.newsinsurance.com
HOME OWNER QUESTIONAIRE
 
Quote Date : - - (mm/dd/yyyy)
Full Name :
Location :
City :
State : Zip Code :
Phone Number :
Cell Phone Number :
Business Number : Ext.
Current Policy Date (mm/dd/yyyy) : Expiry Date :
Social Security Number :
E-Mail :
Year Built : Square Footage : Is this your
Has your home ever Renovated? :
Yes No 		 
If "YES", please check the choices that apply :
Plumbing Year renovated :
Roofing Year renovated :
Electric Year renovated :
Heating Year renovated :
Build Type : Building Condition :
Occupancy Type : Structure Type :
Construction Quality : Condition of Roof :
Roof Material :  
If "other" please specify :  
How May Fireplaces do you have?
 
HOME SECURITY
 
Is your Home a gated Community? Does your Home have fire Sprinklers?
Is your home privately gated? What type of Security System ?
Do you have a Swimming Pool?  
If "YES" check the ones that apply:  
Approved Fence  
Above Ground In-Ground  
Slide    
 
PRIOR COVERAGE
 
Who was your prior insurance provider? Have you had any losses in the past 3 yrs.?
What was your prior Policy No.? If so, what type of claim did you have?
  If so, what was the amount? $
 
GENERAL INFORMATION
 
Is you building undergoing renovation or reconstruction?
If so, what is the total completed value & date of completion?:
 
Do you own any Recreational Vehicles ?
(Snow mobile, Dune Buggy, Mini Bikes etc.)
Do you have coverage Declined, Cancelled or Non-Renewed
Do you have any Live-in employee(s)?
Do you have any Animals or Exotic Pets kept on premises?
Coverage
Building Limits : $
Separate Structure : $
 
SCHEDULED PERSONAL PROPERTY
    Write a Brief Description Total Value
$
$
$
$
$
$
$
$
$
$

* For BLANKET COVERAGE, please specify total dollar amount of all items combined
Additional Comments :
 
Sales Agent:
 
 
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