AQHA - Member Home Insurance Questionnaire

Name

First Name Last Name

Home Phone

Cell Phone

Email Address

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

County Where Property is Located

Mailing Address (please list if different than Property Address listed above) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Have you lived at the current Property Address less than 60 days?

Yes
No

If yes, please list prior address below

Prior Address (please list if you have lived at Property Address fewer than 60 days) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

CONSUMER REPORT NOTIFICATION

An insurance score, based on credit information, is ordered (where allowed) when obtaining an insurance quote. Current carrier, MVR and CLUE reports are also ordered as part of the underwriting process. By completing and submitting this form, you hereby grant permission for us and/or the insurance company to access these reports for the use of quoting your desired insurance products. If you agree, please indicate below.

I Agree

Desired Effective Date

Is the property your primary address?

Yes
No

If not, please explain below

Rating Info

Is the property Inside City Limits?

Yes
No

Miles From Nearest Fire Station

Fire Protection Provider

If you know your Fire Protection Class, please list below

Dwelling Type

Construction Type (i.e. frame, brick, stucco, etc.)

Roof Type (i.e. composite, shake, metal, etc.)

Roof Shape (i.e. pitch, flat, etc.)

Primary Heat Type (i.e. gas, electric, etc.)

Square Feet Living Space

Year Built

Swimming Pool

Yes
No

Does the applicant/tenant have a dog(s)?

Yes
No

If yes, please list the number and type below

Does the applicant/tenant have horses?

Yes
No

If yes, please list the number of horses below

Number of occupants in the insured dwelling

Number of people you employ for more than 9 hours per week (i.e. Gardener, Housekeeper, Caregiver, Nanny, Chef, Chauffer, etc.)

Any losses/claims within the last 7 years?

Yes
No

If yes, please describe the type of each loss, date of each loss and amount paid for each loss below

Renovation Information

Wiring Info

Wiring Year

Plumbing Info

Plumbing Year

Heating Info

Heating Year

Roofing Info

Roofing Year

Coverages

Dwelling Coverage

Other Structures

Personal Property

Loss of Use

Personal Liability

Medical Payments

Deductible

Theft Deductible

Wind Deductible

Credits

Limited Access

Yes
No

Protective Devices

Yes
No

Prior Address

Has the applicant been at this address less than 3 years?

Yes
No

Prior Carrier

Prior Insurance Company

Prior Effective Date

Prior Expiration Date

Prior Policy Number

Prior Policy Premium

Reason for no prior insurance

Reason for non-standard

CLUE

Clue is ordered on all new business in states where it is allowed. This is a standard practice. We may be need to collect signatures if required by the state before ordering this report.