CONFIDENTIAL UNDERWRITING QUESTIONNAIRE

Either PRINT this form out and fax - or fill in this e-form. Our staff will contact you within 24 hours.

Please provide the following information for all residential properties you own or occupy - for multiple locations print and complete the location address up to the auto section for each location.

To provide a complete analysis FAX the declaration pages from each insurance policy Including flood, excess flood, wind, earthquake, elevation certificate to: (262) 478-1001 attn: Large Home Underwriting Program

*required fields

General Information:
*Insured Name:
Spouse Name:
Occupation, if retired, Occupation prior to retirement:
*Home Phone Number:
Business Phone Number:
Cell Phone Number:
Business Fax:
Home Fax:
*Email Address:
*Location Address:
Year Built: Renovation Year, if any
Construction Type:	Please Choose Brick Frame Masonry Reinforced Masonry Fire Resistive Other
Replacement Cost of Dwelling:
Total Square Footage:
Number of Stories:	Please Choose One Two Three Four
Basement Type:	None Finished UnFinished
Roof Configuration:	Please Choose Hip Gable Flat
Roof Covering:	Please Choose Shingles Cement Tiles Clay Tiles Metal Roof Composite
Hurricane Protection - All Openings:	Please Choose Impact Glass Shutters None Other Information or Comments
Backup generator:	Yes No | Size in KW
Fire and Burglary Protection: Check all that apply	Central Station Alarms | Interior Sprinkler System Gated Community | Perimeter Gate Closed Circuit TV | Lightning Protection Doorman
Within 1,000 feet of fire hydrant?	Yes No
	Within 5 miles of Fire Dept? Yes No
If no hydrants, what is water source:
Caretaker:	Yes No
	Lives on Premises? Yes No
Domestic Employees?	Yes No
	If Yes: How Many Full Time Inside Part Time Inside Full Time Outside Part Time Outside
Pool:	Yes No
	Fenced: Yes No
Contents Replacement Cost:
Other Structures and their Replacement Cost: (i.e. Guest House, Detached Garage, Pool, Cabana, Tennis Courts etc.)
Insurance Claim Information: Claim amount, year, description (past three years):
Auto
Number of Drivers:	Please Choose 1 2 3 4 5 6 7
Number of Autos:	Please Choose 1 2 3 4 5 6 7 8
Insurance Claim Information:
Valuable Articles - Jewelry Collection: Please complete the following or provide current policy pages.
Total Scheduled Limit:
Highest Valued Item Limit:
Blanket Limit - Total Limit:
	Per Item Maximum Please Choose $10,000 $20,000 $50,000
Storage:	Please Choose Safe Bank Vault None
Valuable Articles - Fine Art Collection: Please complete the following or provide current policy pages.
Total Scheduled Limit:
Highest Valued Item Limit:
Blanket Limit - Total Limit:
	Per Item Maximum Please Choose $10,000 $20,000 $50,000
Exhibition of any Art:
Umbrella:	Please Choose $1,000,000 $2,000,000 $5,000,000 $10,000,000 $20,000,000 $50,000,000
Miscellaneous: have any? Please include policy declarations pages.
Recreational Vehicles:	Yes No
Watercraft:	Yes No
Aircraft:	Yes No
Collectors/Exotic Cars:	Yes No