Home Update Questionnaire

Your information

Name (as it appears on policy)*

First Name First Name

Phone Number*

Email Address*

Address*

Street Address Address Line 2 City State ZIP Code

Roof Material*

Age of Roof*

Warranty of surface material, in years*

Condition of Roof*

Additional Comments

Pipes made of*

How old is the plumbing or in what year was it last updated?*

Was the work performed by a licensed plumbing contractor?

Please describe the extent of the work completed

Additional Comments

Please check all that apply to your electrical system*

Amperage Rating*

How old is the electrical system or in what year was it last updated?*

Was the work performed by a licensed electrical contractor?

Please describe the extent of the work completed

Other Comments

Type of Heating/Cooling System*

If applicable, please indicate oil tank location.

How old is the heating system or in what year was it last updated?*

Is it serviced annually?*

Date last serviced*

Is there a secondary or supplemental heat source?*

If yes, was it professionally installed?

Is it cleanded or serviced annually?*

Type of Hot Water Heater*

When was it installed?*