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This confidential questionnaire is the first step in providing you with a personal analysis of your insurance needs. You may also want to have the following documents available to assist you in completing this questionnaire:
Nameyour full name
I. PERSONAL INFORMATION
Your Full Name
DOB
SS#
Occupation
Employer
Spouse’s Full Name
DOB
SS#
Occupation
Employer
Names and ages of dependent children:
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Telephone #:
Email Address:
II. RESIDENCES (Including plantations and farms for personal use)
1) PRIMARY RESIDENCE please complete separate form for any other secondary or rental residences
Street Address
2.) Property Details:
Year Build
Construction Type
Type of Roof
Square Footage
Acreage (If applicable)
Finished Basement
Please check all that apply:
If the fire dept. is over 5 miles away, is it paid or volunteer?
Is the home located within five (5) miles of the ocean?
Pool On Premises?
If yes, is it in-ground or above-ground?
Fenced in?
Outdoor Trampoline?
If yes, is it enclosed?
Is the house vacant?
If yes, please explain
Any Pets?
If yes, please provide details
Any detached structures on the property?
If yes, please explain
Do you presently have any contents in a storage facility?
If yes, please provide the location address
Is the home currently undergoing any renovations or construction? If yes, please provide the anticipated start and finish date, the type of work to be done, and the value of the renovations.
Do you operate a business out of your home?
If yes, please provide details, which include the type of business, # of employees (if any), and the # of clients in your home per week.
Have there been any losses in the past five (5) years?
If yes, please provide dates and descriptions of the loss(es)
Mortgagee name and address (If applicable)
Total Balance on mortgage(s)
Flood Coverage:
Is there presently a flood policy in place for this location?
If yes, which carrier underwrites the coverage?
If you have a FEMA policy, do you have separate flood policies for each of your detached structures, such as a garage, spa, deck, or patio?
Are there any contents in your finished basement?
If yes, please describe
Domestic Employees:
Do you have any domestic employees (Nanny, housekeeper, etc.)?
If yes, please specify and advise how many are full-time and how many are part-time employees.
Total annual payroll
Are any of the domestic employees employed by a separate entity?
If so, please provide details and the name of the entity and your relationship/affiliation.
III. AUTOMOBILES
Vehicle Information:
Year
Make
Model
Vehicle Identification Number
Year
Make
Model
Vehicle Identification Number
Year
Make
Model
Vehicle Identification Number
Year
Make
Model
Vehicle Identification Number
Are each of the above vehicles registered at your primary address?
Are any of the above vehicles used to commute to/from work?
If yes, which vehicle(s) and how many miles each way is the commute?
Are any of the above vehicles financed or leased?
If yes, which vehicle(s) and please provide name and address of loss payee and/or lease company
Any company vehicles?
If yes, please provide details
Is the company vehicle registered and insured by you or your employer?
Please provide details for any watercraft or recreational vehicles (snowmobiles, mobile homes, motorcycles, yachts, etc.) you own
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Driver Information:
1)
Driver Name
Date of Birth
Driver's License #
State Issued
Driver Which Vehicle
2)
Driver Name
Date of Birth
Driver's License #
State Issued
Driver Which Vehicle
3)
Driver Name
Date of Birth
Driver's License #
State Issued
Driver Which Vehicle
4)
Driver Name
Date of Birth
Driver's License #
State Issued
Driver Which Vehicle
Valuable Possessions:
Valuable Item
Total Estimated Value($)
Kept in safe or bank vault?
Jewelry
Fine Arts
Silverware
Wine
Furs
Coins/Stamps
Firearms
Other Collectibles
From the above total value, are there any specific jewelry or fur items valued at $5K or more?
From the above total value, are there any specific fine arts items valued at $50K or more?
If you presently do not have any scheduled or blanket Valuable Items coverage, are you relying on your homeowner policy alone to provide coverage for your valuables?
If yes, are you aware that it offers very limited coverage?
Please select all that apply to you:
V. PERSONAL EXCESS LIABILITY
Approximate Net Worth (Include value of owned vehicles, valuable items, residences, investment properties, vacant land, watercraft, and major equity investments):
Below are some of the scenarios that may present an increased liability exposure:

Thank you for providing Allegiance Insurance Brokers, Inc. with the information necessary toanalyze your current personal insurance portfolio. We will use this information to address anycoverage gaps or deficiencies, offer recommendations to improve your plan, and illustratemarket alternatives as appropriate.


We look forward to discussing our improvements and recommendations with you.


Your personal risk management and advisory contact at Allegiance Insurance Brokers, Inc. is:


Jason Street, President

(973)477-4269(P), (973)556-1979 (F)

Jason.Street@AllegianceInsuranceBrokers.com

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