William H Connolly & Co.: Insurance Risk Management
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Personal Insurance
Homeowners Questionnaire
Renters/Condo Questionnaire
Automobile Insurance
Chubb Personal Insurance

Homeowners Insurance Questionnaire

If you are interested in getting to know our homeowners programs or would like a quote, please fill out the form below. You will be contacted with 24 hours (if you submit this information on a weekend, you will be contacted on Monday).

Date:
 Your Name:
Address:
 City:
State:
Zip:
Home Phone:
 Work Phone:
Email:
When/where should we contact you?
How did you hear about us?

 

Homeowners Insurance Application

Person/s Insured (Full Name/s):

Property Address:
 City:
State:
Zip:
Year property built:
 Square footage of living area:
Type of construction (frame brick):
Type of siding (vinyl, aluminum, stucco):
Type of heat:
 Oil tank (if so, give location):

Protective devices (check all applicable):

smoke detectors
fire alarm
burglar alarm

 

local alarm
central alarm
Number of families:
 Amount of dwelling coverage:

Any claims in past three years?
 Yes No
Type of claim and amount paid:
Current insurance carrier:
 Policy expiration date:
Comments/questions:

Certain features of any insurance policy may not be abailable in your state. All policies must be consulted for precise terms and conditions. Coverage is not bound until you receive a written insurance binder from William H. Connolly & Co.

 
   
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