HOMEOWNERS Insurance Questionnaire

EUROPEAN-AMERICAN INC.

Name

Street

City

County

State

Zip

Telephone

e-mail

Telefax

Social Security No.

Occupation

Date of Birth (mo/day/year)

How many years there?

Address of property ( Full address)
Street
City / County
State / Zip

Limits of Insurance Required:

Liability (choose only one limit, which will apply to all liability coverages)

or larger limit


Property Values (actual cash value or replacement cost) - please check one

Description	$ Amount	ACV	Replacement Cost
Building
Additions & Alterations
Contents
Other Structures 1
Other Structures 2
Other Structures 3

Property Deductible:

Theft Extension: (Fine Arts, Silver, Jewelry, Furs, Coins, Stamps, Guns, etc.)

Please click here to use separate form to submit your inventory and limits.

Property Protection

Distances to the nearest fire hydrant (feet)
Distances to the nearest fire station (miles)
Distances to the nearest shore (ft./mi)

Alarms:

Central Station	Burglar	Fire
Local (or Direct)	Burglar	Fire

Property Construction

Other

Any pets, please describe

Any business conducted on the premises, please describe

Any losses - 3 years (please provide date, description, and amount paid

Note: Completion of this questionnaire does not constitute a binder or obligate the applicant to purchase this insurance.

Desired Effective Date:
Name:	Title:	Date: