Personal Lines Questionnaire | Starkweather & Shepley Insurance Brokerage

Client Code (As shown in email)*

Client Name*

Name of Person Completing this form*

First Last

Contact Email*

Contact Phone*

Phone Type*

Home
Office
Mobile

Was this form Prepared for Another Party?*

Yes
No

Name of Person This Form is Prepared For*

First Last

Prepared For Contact Email*

Prepared For Contact Phone*

Phone Type*

Home
Office
Mobile

Property Information

Owners Name*

First Last

Property Address*

Street Address Address Line 2 City State ZIP Code

Any changes to any property insurance amounts that you have chosen?*

Yes
No

Please describe changes.*

Do you rent your home for any part of the year?*

Yes
No

Number of weeks per year you rent your home?*

Whats is the Source of advertising your home?*

AirBnB
Homeaway
VRBO
Other

If seasonal property, do you have?*

Caretaker
Home Watch Service
Automatic Delivery
Other
N/A

Please Describe*

What year were the following systems updated?

Roof- If not known, please put N/A*

HVAC- If not known, please put N/A*

Plumbing- If not known, please put N/A*

Electrical- If not known, please put N/A*

Do you have an active central monitoring alarm station for Burglary or Fire?*

None
Burglary
Fire

Do you have any of these security features in your home?*

None
Low Temperature
Water Detection
Permanent Generator
Other

Describe Other Security Features*

Do you have any other property that we do not currently insure?*

Yes
No

Please list addresses of other properties.*

Any properties titled or recently retitled under a trust or LLC?*

Yes
No

Please list properties titled/retitled under a trust or LLC., include name of trust.*

Do you conduct any business operations from your home?*

Yes
No

Please describe home business operations.*

What type of energy is used to heat your home?*

Gas
Electric
Oil
Solar
Other

Describe the other energy source*

If you have oil, where is your tank located?*

Inside
Outside
N/A

Vehicle Information

Have you purchased, leased, sold or disposed of any motorized vehicles insured with us?*

Yes
No

Which Vehicle(s)?*

Motorhomes
Mopeds
Motorcycles
Snowmobiles
ATVs
Aircraft
Watercraft
Golf Carts
Other

Please Describe Vehicle(s).*

Do you use any of your auto(s) for business/income producing purposes?*

Yes
No

Please describe purposes.*

Would you consider a proposal to increase your Auto Liability and/or Uninsured limits?*

Yes
No

Do you use your vehicle(s) for ride sharing for a fee?*

Yes
No

Please describe ride sharing.*

Any additional licensed drivers in your household that have not been reported to us?*

Yes
No

Please describe additional licensed drivers.*

Collections

Any additions to jewelry, silver, furs, collectibles, fine arts, or antique cars?*

Yes
No

Please describe collections.*

(Jewelry, Precious Metals, Furs, Collectibles, Fine Arts, or Antique Cars?)

Miscellaneous

Do you own, lease, or rent a dock?*

Yes
No

Please describe.*

Do you have any children away at school?*

Yes
No

Please describe.*

Do you own a drone?*

Yes
No

Excess Umbrella Liability

Is anyone in the household a board member for any non-profit organizations?*

Yes
No

Please describe.*

Do you employ domestic staff?*

Yes
No

Please describe.*

Do you have any specific questions or comments regarding your existing policies that you would like us to address prior to renewal?*

If no, please enter N/A

Are there any material items that are not reference in this survey that we should be aware of?*

If no, please enter N/A

Additional coverages may be available to provide broader protection. Please select any items below that you would like more information on:*

Flood
Life
Disability
Sewer Back Up
Umbrella / Excess Liability
Earthquake
Other
N/A

Service Representative

Would you like to be contacted by your service representative?*

Yes
No

Contact Method*

Email
Phone

Contact Email Address*

Contact Phone Number*

Best time to call?*

Morning
Afternoon
Early Evening

Would you be interested in a self-service client portal, if we made one available?*