R. R. Ragette   Insurance Agency, Inc. Home Insurance Questionnaire Contact Us

About Fire Hazard Insurance.com Insurance Questionnaire: To contact us about home fire hazard insurance, please fill out the online form below as completely as possible. If you prefer not to fill out the form, you may e-mail or call us. Please include your name and phone number with any e-mails. We are licensed to offer insurance only in the states of New York and Connecticut. First Name: Last Name E-mail Address: Home Phone: Work Phone: Address: City: State Choose One New York Connecticut Zip Code: Previous Address (within last 6 months): Address: City: State Zip Code: Currently insured with: Current annual Premium: Social Security Number: Type of Home Choose One Primary Secondary Check all that apply: Neighborhood Home & Safety Program Non-Smoking Household Credit Deadbolt Credit Fire Extinguisher Burglar Alarm Code Choose One Central Station Police Dept. Local Fire Alarm Code Choose One Central Station Fire Dept. Local Roof Type Choose One Asphalt fiberglass clay, slate, or title Wood shake Wood shingle Architecture shingle Other Construction Type Choose One Frame less than 10% brick Greater than 67% brick veneer Brick stone masonry Frame with alum siding Log home Asbestos shingle 10-33% brick veneer 34-66% brick veneer Is The Fuel Tank Underground? Yes No Alternate Heat Type: Yes No Home Under Construction: Yes No Residence Type Choose One Primary Secondary Market Value Replacement Cost Loss Date Choose One fire or removal Lightning Windstorm Hail Water damage – weather Water damage – non weather Water damage – sewer backup Freezing Loss Date Choose One fire or removal Lightning Windstorm Hail Water damage – weather Water damage – non weather Water damage – sewer backup Freezing Loss Date Choose One fire or removal Lightning Windstorm Hail Water damage—weather Water damage—non weather Water damage—sewer backup Freezing Have you or your spouse filed bankruptcy in the past 5 years? Yes No Do you own a dog? Yes No     Breed of dog: Has your property insurance been declined, cancelled, or non-renewed in the past 3 years? Yes No Is the home vacant, unoccupied, or for sale? Yes No Explanation: Do you conduct business on premises? Yes No Explanation: Do you own an animal that is vicious or has previously bitten or injured? Yes No Explanation: Do you have a swimming pool? Yes No       Is it in-ground? Yes No       Is it fenced? Yes No       Do you have a slide or diving board over 3 feet high? Yes No Do you have a trampoline, skateboard ramp or bicycle jump? Yes No Is the dwelling subject to flood, tidal wave, or wavewash? Yes No Your Comments or Questions:   Entire publication copyright  © 2002 by R.R. Ragette Insurance Agency, Inc.