to main page           send e-mail


      

   Providing businesses and individuals

                    peace of mind

 






 

155 N. Ft. Thomas Ave.

Ft. Thomas, KY  41075

859-441-4100 phone

859-572-3056 fax

www.penderyins.com

 


Homeowner Insurance Questionnaire
 

Please complete the following questionnaire and click 'Submit.' A representative will contact you shortly.

Name         

Phone        

Cell              

Address     

                      

Previous Address (if less than 3 years)

                    

                  

Birthdate   

Email          

Social Security #

                 

Number of Household Residents

                   

Smoker?    

Occupation

                  

 

Homeowner Insurance Information

 

Current Insurance Carrier 

                  

How Long?    Year Built

Year of Updates:   Plumbing Electric Heating Roof

#of Stories  Square Footage %Brick %Frame %Other

Fireplace/Wood Stove # of Bathrooms: Full Half

Garage: Attached Detached # of Cars

Deck/Porch: sq/ft  Finished Basement: sq/ft

Sump Pump Battery Backup Air Conditioning

Distance to Fire Dept Distance to Hydrant

Fire Extinguisher Dead Bolts Smoke Alarm  

Monitored Alarm System

Trampoline Pool  Pool fenced Diving Board Slide

Water Backup Earthquake

Business on Premises? If yes, describe

Animals on Premises?   If yes, describe

Claims in last 5 years? If yes, describe:

 

Amount of Insurance:

Dwelling:

Other Structures: Describe

Contents Liability  

Medical Payments

Deductible

Any scheduled jewelry, fine arts, collections, etc?

 

 

To provide a quote, our insurance companies use information such as driving records, claims and credit history from consumer reporting agencies.

 

 

 

 

GOOD STUDENT____ AWAY AT SCHOOL ______  WITH VEHICLE OR WITHOUT

 

 

To provide a quote, our Insurance companies use information such as driving records, claims and credit history from consumer reporting agencies.