Gallagher Private Client Personal Risk Profile Form

Please select your gender. *

Please select their gender. *

Are any household members elected officials or politicians? *

Do any household members sit on any boards, or volunteer time/services for non-profits in any official capacity? *

Have you had any claims in the past five years? (Include home, auto, valuable articles, etc.) *

Are there any trusts or LLCs involved with the ownership of your homes and/or vehicles? *

Any declinations/cancellations/non-renewals in the last 5 years? *

Any pets? Bite history? Breeding? *

Will the home be unoccupied more than 30 days? *

Have any renovations been done? *

Are you willing/planning to install an alarm system? *

Is there a fire hydrant within 1,000 feet of your home? *

Does this home have radiant flooring? *

Was the electrical update partial or complete? *

Select the type of electrical system. *

Was the plumbing update partial or complete? *

Are there any known leaks? *

Was the heating update partial or complete? *

Is there an attic? *

Is the attic unfinished, partially finished, or fully finished? *

Are there any detached structures on the property? *

Any firearms in the house? *

Is ammunition kept separate in a locked location? *

Do you need additional coverage for firearms? *

Is there or did the property ever have an underground oil tank? *

Was the underground oil tank removed? *

Does the trampoline have netting? *

Does your dog have a bite history? *

Do you have any collections you would like to insure? (I.e. Jewelry, Fine Arts, Silverware, Musical Instruments, Wine, Camera Equipment, Computers, etc.)

Are there any overhanging tree limbs/branches? *

Are you interested in earthquake coverage? *

Do you have an elevation certificate? *

Is the home built over water? *

Has this home had any prior flood losses? *

The National Flood Insurance Program (NFIP) offers coverage limits up to $250,000 for buildings and up to $100,000 for contents. Are you interested in quotes up to your homeowners dwelling and contents limit (if over they are $250k/$100k)? *

Is there machinery that services the building in the basement? (E.g. Central air conditioner (Including external compressor), Furnace, Hot Water Heater, Heat Pump, Including external compressor), Elevator Machinery and Equipment) *

What is the approximate value of the machinery that services the building? *

Are there any washers/dryers/food freezers located in the basement? *

What is the approximate value of the washers/dryers/food freezers located in the basement? *

Will the home be unoccupied more than 30 days? *

Have any renovations been done? *

Are you willing/planning to install an alarm system? *

Is there a fire hydrant within 1,000 feet of your home? *

Does this home have radiant flooring? *

Was the electrical update partial or complete? *

Select the type of electrical system. *

Was the plumbing update partial or complete? *

Are there any known leaks? *

Was the heating update partial or complete? *

Is there an attic? *

Is the attic unfinished, partially finished, or fully finished? *

Are there any detached structures on the property? *

Any firearms in the house? *

Is ammunition kept separate in a locked location? *

Do you need additional coverage for firearms? *

Is there or did the property ever have an underground oil tank? *

Was the underground oil tank removed? *

Does the trampoline have netting? *

Are there any overhanging tree limbs/branches? *

Are you interested in earthquake coverage? *

Do you have an elevation certificate? *

Is the home built over water? *

Has this home had any prior flood losses? *

The National Flood Insurance Program (NFIP) offers coverage limits up to $250,000 for buildings and up to $100,000 for contents. Are you interested in quotes up to your homeowners dwelling and contents limit (if over they are $250k/$100k)? *

Is there machinery that services the building in the basement? (E.g. Central air conditioner (Including external compressor), Furnace, Hot Water Heater, Heat Pump, Including external compressor), Elevator Machinery and Equipment) *

What is the approximate value of the machinery that services the building? *

Are there any washers/dryers/food freezers located in the basement? *

What is the approximate value of the washers/dryers/food freezers located in the basement? *

Are there any recent violations, accidents or claims that have occurred in another state? *

Have any listed operators had any license suspensions/revocations within the past 6 years? *