Homeowner Insurance Survey - IRMS Insurance and Risk Management Services

Contact Information

Client Name

Contact Name

First Last

Phone Number

Email Address

Client Information

Date of Birth

Occupation

Spouse or Roommate's First Name

First Last

Spouse or Roommate's Date of Birth

Spouse or Roommate's Occupation

Who owns the property to be insured? (i.e. Individual, Trust, Corporation, etc.)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone Number

Mobile Number

Email Address*

How did you find out about IRMS?

Other (If other please specify)

How quickly do you need your quotation?

Have you, your spouse, or your roommate ever been involved in a bankruptcy or foreclosure or convicted of arson or fraud?

If yes, provide details

When do you want your policy to be effective?

How long have you lived at your current address?

List the insurance company that currently insures the property to be insured.

List the expiration date of your current policy (mm/dd/yyyy)

Have you reported any claims in the past 5 years under any homeowner's policy in any state?

If yes, provide details

Property Information

Address of the Property to be Insured

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Is the property located in a community or subdivision?

If yes, what is the name of the community or subdivision?

What is the dwelling description for this property?

What is the occupancy of this property?

If seasonal, please provide the name and phone number of the person or company watching your unit.

If seasonal, which months during the year do you occupy the property?

Do you rent the property?

If you rent the property, which months during the year do you rent the property?

If you rent the property, what is the minimum amount of time (week/months/annually) each renter will occupy the property?

Is a business operated at this property?

If yes, provide details

How many feet is the property from the nearest fire hydrant?

How many miles is the property from the nearest Fire Station?

Which Fire Department would respond to this property?

Do you own any watercraft or recreational vehicles?

If yes to above provide the Year, Make and Model.

Do you have a trampoline located at this property?

Do you have any pets or other animals living at this property?

If yes, list type and breed (s)

Have there been any instances of animals biting anyone?

In what year was the property built?

If this property is more than 20 years old, when is the last time you renovated the roof?

If this property is more than 20 years old, when is the last time you renovated the plumbing?

If this property is more than 20 years old, when is the last time you renovated the electrical wiring?

If this property is more than 20 years old, when is the last time you renovated the Heating/Air Conditioning Unit?

What year is your hot water tank?

Do you have any structures that are not attached to the main property?

Garage
Carport
Guest Home
Shed
Storage unit (offsite)
Other (Fence gazebo, waterfall, greenhouse)

Check all that apply to this property

Pool
Jacuzzi
Hot Tub
Spa
Diving Board
Slide
None of These

If you have a pool, do you have a protective barrier surrounding your pool?

Fence
Pool Enclosure

Do you have a Fireplace or Wood Stove?

If yes, is it Electric or Gas

If you have security devices in your property, check all that apply

Do you have any jewelry, fine arts, silverware, furs, etc. that need to be scheduled?

Do you have a Flood Policy in place?

Do you have a Flood Elevation Certificate for this property?

Do you have completed mitigation forms for this property

Do you own any other properties we are not insuring?

Replacement Cost Information

How many floors does this property have?

How many square feet of air-conditioned space does this property have?

What is the foundation type?

What is the construction type?

What is the shape of the roof?

What is the roof material?

How many cars fit into the garage and/or carport(s)?

Kitchen Design:

Builder's Grade
Custom
Designer

How many bathrooms does this property have?

Bathroom Design:

Builder's Grade
Custom
Designer

Purchase price of your property

Was this home purchase in a foreclosure or short sale?

Replacement cost value of your property less land value

Please include the percentage of each type of flooring in the unit (must add up to 100%)

% of Carpet

% of Ceramic Tile

% of Hardwood

% of Marble

List Other Types (with %)

Any Additional Comments

By Checking this Box, you certify that all information provided is accurate.*

Are you currently a client of IRMS?*

If yes, who is your agent?*

If no, have your spoken to any of the following agents?**

CAPTCHA