Name
Address
City
State, Zip Code
Home Phone
Current Insurance Company
Current Premium
Renewal Date
Employed Yes No
Work Phone
E-mail Address
Own Your Home? Yes No
Frame Brick Condo Mobile
Current Home Premium
Home Insured for:
Year Built
Social Security Number
Date of Birth (03/12/1975)
Car #1
Year Make Model
Vehicle Identification Number (can be found on your registration, current policy, car dash or driver's side door)
Miles driven annually: Car mostly used for: Miles driven one-way:
Car #2
Year Make Model
Vehicle Identification Number (can be found on your registration, current policy, car dash or driver's side door)
Miles driven annually: Car mostly used for: Miles driven one-way:
Car #3
Year Make Model
Vehicle Identification Number (can be found on your registration, current policy, car dash or driver's side door)
Miles driven annually: Car mostly used for: Miles driven one-way:
Car #4
Year Make Model
Vehicle Identification Number (can be found on your registration, current policy, car dash or driver's side door)
Miles driven annually: Car mostly used for: Miles driven one-way:
Driver #1
Name Relationship Date of violation (03/17/2005)
Sex Marital Status Type of violation
Driver #2
Name Relationship Date of violation (03/17/2005)
Sex Marital Status Type of violation
Driver #3
Name Relationship Date of violation (03/17/2005)
Sex Marital Status Type of violation
Driver #4
Name Relationship Date of violation (03/17/2005)
Sex Marital Status Type of violation
Swimming Pool Questionnaire
Construction
Length Width
Maximum Depth Minimum Depth
Is pool area fenced? Yes No
Fence Type Height (inches)
Is there a lockable gate? Yes No
Gate Height Type of Lock
Accessories
Are there diving boards? Yes No If yes, how many?
Depth under boards: Board height above water:
Are there slides? Yes No If yes, how many?
Depth under slides:
Miscellaneous
Swimming lessons given? Yes No
Comments and Additional Explanatory Information:
Dog Owner's Questionnaire
Breed of Dog (if mixed, explain two main breeds)
How old is the dog?
Has the dog ever bitten anyone or shown aggressive behavior? If yes, please explain. Yes No
Please explain any type of discipline training the dog may have had.
Has the dog been trained to be an attack or watch dog? Yes No
Where is the dog kept? (house, kennel, chained, fenced yard, etc.)
Is the dog allowed to run free? Yes No
Has the dog been raised from a puppy by the insured? Yes No
General Questionnaire
Do you have any collectibles such as antiques, fine art, stamps, coins, or baseball cards? Yes No
Do you own valuable jewelry, furs, firearms, cameras, etc.? Yes No
Do you operate an office or studio in your home? Yes No
Do you baby-sit in your home? Yes No
Are you interested in flood insurance for your home and personal property? Yes No
Are you interested in earthquake coverage? Yes No
Do you use a wood-burning stove? Yes No
Do you own rental or investment property? Yes No
Do you own a vacation home (i.e. condo, cabin, trailer)? Yes No
Do you own any recreational vehicles (boat, motor home, atv, etc.)? If so, describe. Yes No
Do you carry at least a one-million-dollar umbrella liability policy? Yes No
Do you own a business? Yes No
Do you know anyone else who could benefit from a no-obligation insurance review from our agency?
Name
Phone Number
The Allied Insurance Company will order your credit history from a consumer reporting agency for use in determining an insurance score. This insurance score will be used to underwrite and/or rate your insurance policy. Our inquiry will not affect your credit history in any way.
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