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Home » Our Forms » National Trust Insurance Services – Historic Homeowners Online Questionnaire

Every historic home is different. Consider filling out our form and we’ll get back to you soon.

Get the insurance your historic home needs.

Please complete the form to your best ability. Fields marked with an * are required.

"*" indicates required fields

Step 1 of 8

12%

This field is for validation purposes and should be left unchanged.

Name*

First Name* Last Name*

Date of Birth*

Email*

Phone Number*

Current Mailing Address

Street Address Address Line 2 City State/Prov./Region ZIP/Postal Country

Is the mailing address the name of the property being insured?*

Yes

Effective Date of Coverage*

MM slash DD slash YYYY Effective Date of Coverage*

Year Built*

MM slash DD slash YYYY Year Built*

Square Footage of Home (not including basement)*

Home Information

Home is*

Primary Residence

Builders’ Risk

Rented

Vacation Home

Style of Home*

Colonial

Antebellum

Victorian

Vacation Home Townhome/Row Home

Farmhouse

Federal

Greek Revival

Other

Exterior Construction*

Brick

Stone

Wood Siding

Stucco

Roof Contruction*

Shingle

Tar (flat)

Metal

Tin

Slate

(California Only) Has the home been retrofitted for earthquakes? If so, what year?

Yes

Number of Stories

Age of Roof*

Type of Roof*

Flat

Gambrel

Other

Does the home have a basement?

Yes

Is it finished?

Yes

Approximate % of the basement finished %

Does the home have a sump pump?

Yes

Does it have a battery back-up present?

Yes

Is there any machinery in the basement?

Yes

Does the home have a centrally monitored burglar / fire alarm system?

Yes

Year of electric update

Year of heating update

Year of plumbing update

Has the electric, plumbing, and heating been updated?

Yes

Number of miles to closest Fire Dept?

Number of feet to the closest fire hydrant?

If yes, what year and describe the update.

If yes, name the provider.

Is the home on the national register of historic places?

Yes

Additional Coverage

Choose any that are applicable:

Fine Arts

Jewelry

Wine

Silver

Misc.

Current Carrier

Date purchased

MM slash DD slash YYYY Date purchased

Date purchased

Purchase price of home

Deductible

Current Dwelling limit

Have there been any paid claims for the past 36 months?

Yes

Have you been or are you currently being canceled, declined or non-renewed?

Yes

Are you currently a member of the national trust for historic preservation?

Yes

If yes, please explain.

Did you provide photos and a copy of the current policy?

Are you interested in an automobile or umbrella quote?

One

Two

Three

Additional Notes

Auto Information

Multiple Drivers?

Yes

Primary

State & License #

Date of Birth

MM slash DD slash YYYY Date of Birth

Date of Birth

Education

Employment

Marital Status

Annual Miles

Miles to work/school

Defensive Driving Course (date)

MM slash DD slash YYYY Defensive Driving Course (date)

Defensive Driving Course (date)

Claims / violation history (date and description)

Driver # 2

State & License #

Date of Birth

MM slash DD slash YYYY Date of Birth

Date of Birth

Education

Employment

Marital Status

Annual Miles

Miles to work/school

Defensive Driving Course (date)

MM slash DD slash YYYY Defensive Driving Course (date)

Defensive Driving Course (date)

Claims / violation history (date and description)

Driver # 3

State & License #

Date of Birth

MM slash DD slash YYYY Date of Birth

Date of Birth

Education

Employment

Marital Status

Annual Miles

Miles to work/school

Defensive Driving Course (date)

MM slash DD slash YYYY Defensive Driving Course (date)

Defensive Driving Course (date)

Claims / violation history (date and description)

Multiple Vehicles

Yes

Vehicle #1 - Make

Vehicle #1 - Year

Vehicle #1 - Model

Vehicle #1 - VIN #

Vehicle #1 - Lienholder on vehicle

Vehicle #2 - Make

Vehicle #2 - Year

Vehicle #2 - Model

Vehicle #2 - VIN #

Vehicle #2 - Lienholder on vehicle

Vehicle #3 - Make

Vehicle #3 - Year

Vehicle #3 - Model

Vehicle #3 - VIN #

Vehicle #3 - Lienholder on vehicle

Vehicle #4 - Make

Vehicle #4 - Year

Vehicle #4 - VIN #

Vehicle #4 - Lienholder on vehicle

Prior Insurance Carrier/Expiration Date:

MM slash DD slash YYYY Prior Insurance Carrier/Expiration Date:

Prior Insurance Carrier/Expiration Date:

Length of continuous Auto Coverage

Limits of Prior Coverage/Deductible:

Other policies in force

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