Homeowner Questionnaire Full Name * Home Number Cell Number * Email * Address Policy Type HomeownerFireRental PropertyCondo Policy Date Have Current Insurance Company --Select--YesNo Current Insurance Company Current Premium Have you had any losses past 3 Years? --Select--YesNo Building Information Year Built Square footage No. of Floor --Select--12345 Building Construction --Select--Wood FrameBrick or ConcreteFire ResistiveOther Is your property? --Select--Owner OccupiedTenant OccupiedVacantUnder course of construction Has the building been renovated? --Select--YesNo Plumbing Electrical Roof Heating Does your Building have the protection below? Fire Sprinkler System --Select--YesNo Guard Gated Community --Select--YesNo Perimeter Protection Gate --Select--YesNo Temperature Monitoring System --Select--YesNo Backup Electrical Generator --Select--YesNo Gas Leak Detector --Select--YesNo External Perimeter Security --Select--YesNo Roof Type : Swimming Pool --Select--YesNo Type of Alarm System NoneLocal BurglarCentral BurglarCentral FireCentral Fire & BurglarSmoke Alarm Coverage Building Limits Umbrella Limits Personal Property Liability Limits Separate Structure Deductible The above information is true to the best of my knowledge. I authorize Insure Pal Insurance Services the use of the above information for the purpose of obtaining a quotation for insurance. I also understand by submitting this information does not mean that I have purchased an insurance policy. This information is used only to provide a quote.