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Home » Our Forms » Personal Insurance Questionnaire

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

Get the personal insurance coverage for your needs.

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

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Step 1 of 18

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General Information

Name Insured (1)*

First Name* Last Name*

Date of Birth*

MM slash DD slash YYYY Date of Birth*

Occupation/Employer*

Name Insured (2)*

First Name* Last Name*

Date of Birth*

MM slash DD slash YYYY Date of Birth*

Occupation/Employer*

Current Mailing Address

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

Email*

Contact Phone Number*

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*

MM slash DD slash YYYY Year Built*

Date Built*

MM slash DD slash YYYY Date Built*

Occupancy*

Primary Residence

Builders’ Risk

Rented

Vacation Home

Style of Home*

Family Dwelling

Condo

Townhouse

Construction*

Brick

Wood Siding

Stone

Stucco

Frame

Masonry

Type of Roof*

Shingle

Tar (flat)

Metal

Tin

Slate

Other

Age of Roof*

MM slash DD slash YYYY Age of Roof*

Age of Roof

Number of Stories*

Does the home have a basement?*

Yes

Approximate % of the basement finished %

Description of other structures: (i.e. Pools, Gazebos, Walkways etc.)

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

Yes

If so, what year?

Is the home located in a flood zone? If so, is there a current flood policy?*

Yes

Has the electric, plumbing and heating been updated?*

Yes

If yes, what year and describe the update.

Electrical Update Year

MM slash DD slash YYYY Electrical Update Year

Electrical Update Description

Plumbing Update year

MM slash DD slash YYYY Plumbing Update year

Plumbing Update Description

Heating Update Year

MM slash DD slash YYYY 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 Dept?*

Number of feet to the 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?

Details of claim activity ( Date, Amount Paid, Description of damage and what occurred)

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

Yes

If yes, please explain

Any dogs on the premises?

Yes

If so, what breed?

Additional Coverage

Choose any that are applicable:

Fine Arts

Jewelry

Wine

Silver

Misc.

Specific Collections Details

Umbrella Limit Requested

Auto Information

Do you need an auto quote?*

Yes

How many drivers?*

Plus 4 or more 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)

Vehicles

How many vehicles?

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 - Model

Prior Insurance Carrier/Expiration Date:

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

Prior Insurance Carrier/Expiration Date:

Limits of Prior Coverage/Deductible:

How long have you been insured with your current carrier?

Billing

Preferred Billing Options ( select one)

Monthly

Quarterly

Semi - Annually

Annually

Home Premium Escrowed:

Yes

Mortgagee Clause

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Maury Donnelly & Parr, Inc. is a professional insurance agency that is devoted to keeping our insured protected and providing them with insurance solutions for their needs. MDP strives to offer personalized levels of service in our niche programs as well as a wide range of insurance knowledge to write most classes of business, regardless of their size. Our goal is to provide insurance of the highest quality so every client may obtain coverage levels that are right for their unique situation and to always value coverage over policy price.

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