CONFIDENTIAL UNDERWRITING QUESTIONNAIRE

Bruce Gendelman Company, Inc. Private Client Group

Complete Coverage program for homes over $1 million

Phone (800) 845-4145 x13 Fax (262) 478-1001

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:
Replacement Cost of Dwelling:
Total Square Footage:
Number of Stories:
Basement Type:
Roof Configuration:
Roof Covering:
Hurricane Protection - All Openings:
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:
Number of Autos:
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
Storage:
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
Exhibition of any Art:
Umbrella:
Miscellaneous: have any? Please include policy declarations pages.
Recreational Vehicles: Yes No
Watercraft: Yes No
Aircraft: Yes No
Collectors/Exotic Cars: Yes No




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500 W. Brown Deer Road, Suite 101, Milwaukee, WI 53217
800-845-4145
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