Please complete the following questionnaire completely, and the mail or submit it when finished. Thank you.

Occupation(s) (or if retired):

Is this your primary or secondary residence?

If a secondary residence, please indicate which company insures your primary home. This company may consider insuring your secondary home as well.

With what company do you insure your Mass. vehicle(s)?

Social Security #(s)

Dates of Birth(s)
(Required to quote with some companies; credit check will be done).

Please indicate if the deed to the property is in the name of a trust, LLC, LTD etc., and name the trustees or managing members.

Please indicate the quality of construction for your home:
-- Please Select -- Standard Builder Grade Some Custom Features Custom/Designer

1. Is the home for sale? Yes No

2. Is the home currently under construction or renovation? No Yes

If yes, please explain and indicate when renovations will be completed.

3. Have you made any major changes, renovations or additions to your home in the last 5 years? Yes No

If yes, please describe.

4. What year was your home built?

If your home was built prior to 1983, please indicate updates:

Age of Roof:

Age of Wiring:

Do you have circuit breakers or fuses? Circuit Breakers Fuses

Age of Plumbing:

Are there any lead pipes? Yes No

Age of Heating:

Type of Heating i.e. gas, oil, other? Gas Oil Electric Other

If oil heat, where is the oil tank located?

What is the age of the oil tank?

5. Do you rent the house we insure? Yes No

If yes, for how many weeks out of the year?

6. Do any non-family members reside in your home? Yes No

If yes, please describe the arrangement.

7. Do you have a detached guesthouse, cottage, garage or other structure on your premises? Yes No

8. Is this detached structure rented or held for rental or used for any business during any portion of the year? Yes No

9. Do you have a pool? Yes No

If yes, is it fenced? Yes No

If yes, is there a diving board? Yes No

Is there a slide? Yes No

10. Do you have a wood stove? Yes No

11. Do you own a trampoline? Yes No

12A. Is your home equipped with a smoke detector or fire or burglar alarm? No Yes

If yes, please describe:

If yes, is it hard wired to a central station?

12B. Do you have a caretaker or home watch service? No Yes

If yes, please describe:

13. Are you a member of a Homeowner Association? No Yes

If yes, please describe:

14. Do you maintain an office in your home or use your home for any business purpose such as daycare, music lessons, workshop, room rental, etc? Yes No

If yes, please describe:

15. Has any household member smoked in the last 12 months? Yes No

16. Do you own any animals? Yes No

If yes, what kind?

If you own a dog, what breed* is it?

*note – “mutt” or “mixed breed” is not an adequate description. Please provide the specific breed(s).

17. Do you require jewelry, fine arts, furs, cameras, silver, musical instruments, golf equipment, guns or postage stamps to be insured? Yes No

If yes, please describe in detail:

18. Do you require additional coverage for your computer(s)? Yes No

19. Do you own any recreational vehicles? Such as a boat, dirt bike, jet ski, ATV, snowmobile? Yes No

If yes, please describe:

20. Do you have any domestic employees working more than 16 hours per week? Yes No

If yes, please explain:

21. Have you had any insurance claims in the last five years? Yes No

If yes, please describe:

Please print and mail completed questionnaire to:

Eldredge & Lumpkin Insurance
697 Main St.
Chatham, MA 02633

... or submit questionnaire by e-mail: