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.