What is your first name?
What is your last name?
What is your email address?
What is your occupation and employer name?
What is your date of birth?
MM slash DD slash YYYY
What is your marital status?
What is your spouse's name?
What is their occupation & employer name?
What is their date of birth?
MM slash DD slash YYYY
Primary Residence Risk Management
Please enter your primary home address.
What type of residence is this?
Do you have any full time domestic employees at this location? (Ie. Nanny, chauffeur, chef, gardener, etc...)
How many full time domestic employees do you have?
Do any of the full time domestic employees work 5 days per week at the residence year round?
Do any of the full time domestic employees live at the residence year round?
Do you have any part time domestic employees at this location? (Ie. Nanny, chauffeur, chef, gardener, etc...)
How many part time domestic employees do you have?
Please enter the following information for each domestic employee.
Is there a safe on premises?
Is the safe permanently mounted with a burglary resistive U.L. rating?
Is there an alarm system in this residence?
Alarm System Information
Does your alarm system monitor for smoke/fire?
What type of monitoring does your alarm system have for smoke/fire?
Does your alarm system monitor for break-ins/burglary?
What type of monitoring does your alarm system have for break-ins/burglary?
Is the alarm system activated when the signal is interrupted?
Does the alarm system include radio or cellular communication in addition to a phone line direct dialer?
Is your safe connected to the alarm system?
Other Security Measures
Is your primary residence located in a gated community?
Is vehicle access limited to entrances controlled by guards or locked gates at all times?
Is proper identification required to enter your community?
Are visitors to your community announced?
Does your burglar alarm alert a 24-hour patrol service to dispatch a guard to your residence?
Other Residence Information:
Do you own or regularly use any other residences?
How many other residences do you own or use regularly?
Secondary Residence
What is the address of the secondary residence?
What type of property is the secondary residence?
Does this property have a centrally monitored alarm system?
Please select the active components of your alarm system.
What are the other active components of your alarm system?
How often do you use this residence?
Third Residence
What is the address of this residence?
What type of property is this residence?
Does this property have a centrally monitored alarm system?
Please select the active components of your alarm system.
What are the other active components of your alarm system?
How often do you use this residence?
Fourth Residence
What is the address of this residence?
What type of property is this residence?
Does this property have a centrally monitored alarm system?
Please select the active components of your alarm system.
What are the other active components of your alarm system?
How often do you use this residence?
Fifth Residence
What is the address of this residence?
What type of property is this residence?
Does this property have a centrally monitored alarm system?
Please select the active components of your alarm system.
What are the other active components of your alarm system?
How often do you use this residence?
Condominiums, Cooperatives, and Renters
Are the building entrances manned at all times?
Are the building entrances locked and secured by either a central station or direct burglar alarm or closed circuit TV camera(s) which is monitored 24-hours a day?
Are there any elevators in your building?
Please select the correct option to describe the elevator(s) in your building.
Collections Risk Management
Please select the collection types you would like to provide risk management information about.
Jewelry
What is the approximate value of the jewelry regularly worn?
Do you own any items with a value of $100,000 or more?
Where is your jewelry kept when it is not being worn? (Select all that apply)
What is the manufacturer and model name of your safe?
What is the serial number of your safe?
What percentage of your jewelry collection is kept in your safe?
What percentage of your jewelry collection is kept in the bank vault?
Is the jewelry that is normally stored in the bank vault out of the vault for less than 30 days per year?
When did you last have any of your jewelry items appraised?
Is any portion of your jewelry collection stored at another residence or location besides your primary home?
What is the approximate value of the jewelry kept at another location? (Ex. $10,000)
Do you bring jewelry with you when you travel?
What is the average value of jewelry taken while traveling?
Is jewelry worn or kept in sight at all times during travel?
Please share what security measures are utilized when traveling with jewelry: (Select all that apply)
What other security measures are utilized when you travel with jewelry?
What is the average number of weeks you spend traveling per year?
Fine Art
Do you have a secondary residence where you store scheduled fine art?
What is the approximate value of scheduled fine arts kept at your secondary residence?
Do you store any scheduled fine art in a storage facility?
What is the name of the storage facility?
What is the address of the storage facility?
Are any of your scheduled fine arts ever loaned to galleries or museums?
Do you obtain certificates of insurance from the gallery or museum you loan your art to showing "wall to wall" coverage for your art?
Please identify the items, describe the location of the loan, and enter the length of the loans below.
Are any of your scheduled fine arts ever consigned to a gallery or auction house to sell?
Do you obtain certificates of insurance from the gallery or auction house showing "wall to wall" coverage for your art while it is in their care, custody or control?
Please provide a description of the items what are being consigned to a gallery or auction house.
What is the name of the gallery/auction house?
What is the address of the gallery/auction house where your fine art will be located during this consignment?
Wine
How many bottles do you have in your wine collection?
What is the total value of your wine collection? (Approximate)
How much is your most expensive bottle?
Do you keep your wine in a temperature/humidity controlled space?
Do you keep any of your wine in a wine storage facility?
Select the security measures of your wine storage facility.
What is the name of the wine storage facility you use?
What is the address of the wine storage facility?
Firearms
How many firearms do you have in your collection?
What is the total value of your gun collection?
How much is your most expensive firearm?
What are your firearms used for? (Select all that apply)
What other uses do your firearms have?
Where are your firearms stored? (Select all that apply)
Please enter the other location(s) your firearms are stored.
How often are your firearms used?
Who has access to your firearms?
Comments
Enter any questions or comments below.
Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.
