Owner Survey
Do Not Print.
Form must be completed online or by calling our toll free number at 1(800) 847-7030 and pressing extension 243 Monday through Friday 8:30am - 4:00pm est.
Date:
Insured's Name:
Policy #:
Phone:
911 Address(Physical Address of Property):
Person Interviewed:
How Occupied?
Primary  Secondary  Seasonal
Tenant 
Occupied how long?
Purchased:
Seasonal Rental? Yes  No
If seasonal, rented how long?
If tenant, any Student Housing? Yes  No
For Sale? Yes  No
Number of Families?
Number of Occupants?
Number of Acres?
 
Feet from fire hydrant?
Miles to fire department?
 
Heat Type:
Fuel Storage Tank? Yes  No
Fuel Tank Size:
Fuel Tank Type:
Fuel Tank Location:
Fuel Tank Inground? Yes  No
Fuel Tank Condition:
 
Year Dwelling Built:
Decks? Yes  No
Height:
Age:
Condition:
Poor   Fair Good Excellent
Type of Materials:
Any changes to the structure?
Yes  No
If yes, please explain:
Are there any other structures on premises?
Yes  No
If yes, what are they used for:
 
Pool:
None  Inground  Above Ground
Fenced  Locking Gate
 
Trampoline? Yes  No
Swing Set? Yes  No
Livestock (horses, cattle, etc.)? Yes  No
Livestock Type:
Livestock Number:
 
Dogs? Yes  No
Number of Dogs:
Breed (also needed if mixed):
Age of Dogs?
Dog Temperament?
Dogs Bite History? Yes  No
If yes, please explain:
Other Pets?
 
Recreational Vehicles (snowmobiles, boats, ATV's, jet skis, etc.) Yes  No
If yes, please explain:
 
Any business on the premises? Yes  No
If yes, please explain:
 
Prior losses or claims at this location? Yes  No
Prior losses or claims at other locations? Yes  No
If yes, please explain:
 
Previous Carrier:
 
Other Questions:
Electrical Service: Circuit Breakers  Fuses NA
Size of Electrical Entrance?
  Date By Whom (Insured, Contractor, NA)
Electrical Updated?
Plumbing Updated?
Heating Updated?
Roof Updated?
Fireplace? Yes  No
Pelletstove? Yes  No
Woodstove? Yes  No
Woodfurnace? Yes  No
Make:
Model:
Frequency of Use:
Installed By:
Date Installed:
Are they a contractor? Yes  No
Do you have a mortgage on your dwelling? Yes  No
If yes, Who is the mortgagee?:
Additional Survey Comments:

IMPORTANT NOTICE TO POLICYHOLDER

"Any person who knowlingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation."

As part of our underwriting procedure, a routine inquiry may be made which will provide applicable information concerning character, general reputation, personal characteristics and mode of living. A Consumer Report may be requested by the insurer to which this application is assigned. Subsequent consumer reports may be requested in connection with an update, or renewal, or extension of the insurance to which this application is made. The Applicant, upon written request, will be informed whether or not a consumer report was requested – and if such was requested, informed of the name and address of the consumer reporting agency that furnished the report. The person completing this survey hereby affirms that the statements and representations made herein are true to the best of his/her knowledge.