LS INSURANCE SERVICE | Home Owners Insurance Questionnaire Form

Requester Information

Requester Name:

Property Address:

City

County:

State:

Zip:

Requester Phone Number

Requester Email Address

Owner Information

First Name:

Last Name:

Address:

City

County:

State:

Zip:

Phone Number

Email Address

SSN #:

Owners Date of Birth:

What is your Occupation:

Owner Credit

Any Bankruptcies in the last 5 years?

If "Yes" Discharged?

If "Yes" Date Discharged:

Co-Owner Information

First Name:

Last Name:

Address:

City

County:

State:

Zip:

Phone Number

SSN #:

Date of Birth:

What is the Co-Owners Occupation:

Co-Owner Credit

Any Bankruptcies in the last 5 years?

If "Yes" Discharged?

If "Yes" Date Discharged:

Property Information

Is this a new purchace?

If "NO" Years at location?

Age of Home "or" Year Built!:

How many floors in the home?

What Construction type is the home?

Do you have a basement?

What type of siding is on the home?

What type of Roofing is on the home?

What type of heat is in the home?

If "Oil Heat" Heat Oil tank location:

If "Oil Heat" how old is the oil tank in years?

Date of last Update to Electric?

Date of last Update to Plumbing?

Date of last Update to Heating system?

Date of last Update to the roof?

Property Safty Info

Do you have Smoke Detectors?

How many Smoke Detectors in the home?

Do you have a Carbon Monoxide Detectors?

Do you have a Central Alarm System?

Do you have Deadbolts for door locks?

Is your Property Fenced in?

How far is the nearest fire hydrant from your home?

How far is the nearest fire Station from your home?

Prior Insurance Ino

Prior Insurance if Any:

Prior Insurance EXP.:

Any Claims in the last 5 years?

If "YES" How mAny claims?

If "YES" Last claim date?

If "YES" Claim Reason:

If "YES" Claim Payment Amount:

Outdoor Amenities

Do you have a swimming pool?

If "YES" Do you have a Diving Board?

If "YES" Do you have a Slide?

Do you have a Trampoline?

Pet Info

Do you have any Animals?

If "YES" How many animals do you have?

If "YES" What breed are the animals?

Desired Coverage Limits

Dwelling Coverage (value/cost of the home):

Personal Liability Amount?

Deductible Amount?

Other Services Offered

Would you like us to get you some information about Flood Insurance?

Would you like us to get you some information about Auto Insurance?

Would you like us to get you some information about Watercraft Insurance?