R.R.I.S. Homeowner Questionnaire                 

Please provide the following information:    

(The Referral Agent is the name of your Insurance Agent in our office or how you became aware of our website)

First Name
Last Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Social Security  #
Work Phone
Home Phone
FAX
E-mail
URL

Personal information

Gender Choose One male female Age Choose One 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 Marital Status   Choose One married unmarried divorced Occupation 1 Spouse   Occupation 2   Property Address street city state zip code   About your home no. of units Choose One condo single family residence duplex triplex fourplex 5 or more living sq. footage year built number of levels Choose One 1 2 3 4 5 no. of car garage Choose One 0 1 2 3 4 5 Garage Type Choose One Attached Detached Built-in         no. of bathrooms Choose One 1 2 3 4 5 no. of fireplaces Choose One 0 1 2 3 4 5 swimming pools Choose One No Yes spa Choose One No Yes porch Choose One No Yes deck Choose One No Yes heating Choose One none central wall furnace a/c Choose One No Yes         roof type Choose One composition shingle wood shakes spanish tile concrete/cement-fiber tile rock other roof age Choose One 1-10 years 11-20 years over 20 years construction type Choose One Frame Brick/Masonry Log Adobe Other     foundation Choose One slab raised exterior type Choose One wood siding stucco on frame stucco on masonry paint on masonry solid brick other   Coverage Limits liability requested Choose One $100,000 $300,000 $500,000 $1,000,000 Deductible Choose One 500 750 1000 1500 2500 5000 dwelling     personal property loss of use   Discounts smoke detector Choose One No Yes sprinkler Choose One not applicable partial full (attic, closets, garage) auto insurance company Choose One farmers other burglar alarm Choose One No Yes type of alarm Choose One not applicable central station rings out locally non-smoker Choose One No Yes Fire Safeguard Choose One Gas Shut Off Propane Shut Off All Electric or Solar House Unknown Allow Interior Inspection Choose One No Yes   Insurance information prior/current carrier   no. of claims (in last 3 years)   1. type of claim   amount of claim 2. type of claim   amount of claim 3. type of claim   amount of claim   Comments Please list any additional coverage you need.       Sheri Ritchie / Ritchie & Rose Insurance Services, Inc. Bus  (530) 365-4705   Fax (866) 885-1428   DOI License No.  0F44143