Owner Occupied Survey
Insured 's Name:
Policy #:Trampoline?YesNo
Phone:Swing Set?YesNo
Email Address:Livestock (horses, cattle, etc.)?YesNo
911 Address(Physical Address of Property):Livestock Type:
Street:Livestock Number:
Person Interviewed:Number Dogs:
If Manufactured Home:Breed (also needed if mixed)
Year:Age of Dogs?
Make:Dog Temperament?
Model:Dogs Bite History?
Length:If yes, please explain:
How Occupied:
TenantOwnerOther pets?
Occupied how long?Recreational Vehicles (snowmobile, boats, ATVs, jet skis, etc.YesNo
Seasonal Rental?YesNoIf yes, please explain:
If seasonal, rented how long?
If tenant, any student housing?YesNo
For Sale?YesNoPrior losses or claims at this location?YesNo
Number of Families?
Number of Occupants?Prior losses or claims at other locations?YesNo
Any Smokers in the home?YesNo
If yes:CigarettesCigarsPipesIf yes, please explain:
Any working smoke detectors in the home?YesNo
Previous Carrier:
If Yes:How many?Other Questions:
Any working fire extinguishers?YesNo
If Yes:  How many?Fireplace?YesNo
Any working carbon monoxide detectors?YesNoPelletstove?YesNo
If yes: How many?Woodfurnace?YesNo
Number of Acres?Make:
Feet from fire hydrant?Model:
Miles to Fire Department?Frequency of Use:
Year Dwelling was Built:Installed By:
Decks?YesNoDate Installed:
If yes:Height:Are they a contractor?YesNo
Age:Do you have a mortgage on your dwelling?YesNo
Type of Materials:
Condition:PoorFairIf yes, Who is the mortgagee:
Any changes to the structure?YesNoHeat Type:
If yes, please explain:Fuel Storage Tank?YesNo
If yes:Fuel Tank Size:
Fuel Tank Type:
Are there any other structures on premises?YesNoFuel Tank Location:
Fuel Tank Inground
If yes, what are they used for:Fuel Tank Condition
Electrical Service:
Size of Electrical Entrance? (Amps)
DateBy Whom (Insured, Contractor, NA)
Electrical Updated?
Plumbing Updated?
Heating Updated?
Roof Updated?
Additional Survey Comments/Questions:
"Any peson who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation."
As part of our underwriting procedure, a routine inquiry may be made which will provide applicable information concerning character, general reputation, personal characteristics and mode of living.  A Consumer Report may be requested by the insurer to which this application is assigned. Subsequent consumer reports may be requested in connection with an update, or renewal, or extension othe insurance to which this application is made.  The applicant, upon written request, will be informed whetheror not a consumer report was requested - and if such was requested, informed of the name and address of the consumer reporting agency that furnished the report.  The person completing this survey hereby affirms that the statements and representations made herein ae true to the best of his/her knowledge.