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Home » Our Forms » Personal Insurance Questionnaire (Peace Team)

Everyone’s insurance needs are different. Consider filling out our form and we’ll get back to you soon.

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

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General Information

Named Insured #1

Named Insured #1*

First Name* Last Name*

DOB*

MM slash DD slash YYYY DOB*

SS#*

Occupation/Employer*

Named Insured #2

Named Insured #2*

First Name* Last Name*

DOB*

MM slash DD slash YYYY DOB*

SS#*

Occupation/Employer*

Current Mailing Address*

Street Address* Address Line 2 City* State* ZIP Code*

Contact Phone Number*

Email Address*

Effective Date of Coverage

MM slash DD slash YYYY Effective Date of Coverage

Property Information

Address of Property to be insured*

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

Year Built*

Date Purchased*

MM slash DD slash YYYY Date Purchased*

Occupancy*

Style of Home*

Construction*

Type of Roof*

Age of Roof*

Number of Stories*

Does the home have a basement?*

Yes

Percentage Finished*

Description of Other Structures: (Pools, Gazebos, Walkways etc.)

(California Only) Has the home been retrofitted for earthquakes?

Yes

(California Only) If so, what year?

Is the home located in a flood zone?*

Yes

If so, is there a current flood policy?

Has the electric, plumbing and heating been updated?*

Yes

If yes, what year and describe the update:

Electric Update Year

Electric Update Description

Plumbing Update Year

Plumbing Update Description

Heating Update Year

Heating Update Description

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

Yes

Does the home have any other loss prevention devices?

Back-up Generator

Water Leak Detection

Temperature Monitor

Gated Home

Lightning Protection

Number of miles to closest Fire Department?*

Number of feet to closest fire hydrant?*

Building Coverage Requested*

Contents Coverage Requested*

Deductible Requested*

Wind/Hail Deductible*

Current Insurance Carrier*

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

Yes

Details of Claim Activity: (Date, Amount Paid, Description of damage and what occurred)

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

Yes

If yes, please explain

Any dogs on premises?

Yes

If so, what breed?

Additional Coverages

Choose any that are applicable

Fine Arts

Jewelry

Wine

Silver

Miscellaneous

Specific Collections Details

Umbrella Limit Requested

Auto Information

Do you need an auto quote?*

Yes

How many drivers?*

4 or more

Primary - Name

Primary - State & License #

Primary - Date of Birth

MM slash DD slash YYYY Primary - Date of Birth

Primary - Education

Primary - Employment

Primary - Marital Status

Primary - Annual Miles

Primary - Miles to Work/School

Primary - Defensive Driving Course (Date)

MM slash DD slash YYYY Primary - Defensive Driving Course (Date)

Primary - Claims/Violation History (Date and Description)

Driver #2 - Name

Driver #2 - State & License #

Driver #2 - Date of Birth

MM slash DD slash YYYY Driver #2 - Date of Birth

Driver #2 - Education

Driver #2 - Employment

Driver #2 - Marital Status

Driver #2 - Annual Miles

Driver #2 - Miles to Work/School

Driver #2 - Defensive Driving Course (Date)

MM slash DD slash YYYY Driver #2 - Defensive Driving Course (Date)

#2 - Claims/Violation History (Date and Description)

Driver #3 - Name

Driver #3 - State & License #

Driver #3 - Date of Birth

MM slash DD slash YYYY Driver #3 - Date of Birth

Driver #3 - Education

Driver #3 - Employment

Driver #3 - Marital Status

Driver #3 - Annual Miles

Driver #3 - Miles to Work/School

Driver #3 - Defensive Driving Course (Date)

MM slash DD slash YYYY Driver #3 - Defensive Driving Course (Date)

#3 - Claims/Violation History (Date and Description)

Vehicles

How many vehicles?

Vehicle #1 - Year

Vehicle #1 - Make

Vehicle #1 - Model

Vehicle #1 - VIN#

Vehicle #1 - Lienholder on Vehicle

Vehicle #2 - Year

Vehicle #2 - Make

Vehicle #2 - Model

Vehicle #2 - VIN#

Vehicle #2 - Lienholder on Vehicle

Prior Insurance Carrier

Expiration Date

MM slash DD slash YYYY Expiration Date

Limits of Prior Coverage/Deductible

How long have you been insured with your current carrier?

Billing Options

Preferred Billing Option

Monthly

Quarterly

Semi-Annually

Annually

Home Premium Escrowed

Yes

Mortgagee Clause

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