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Carrier – Underwriting Questions – Stillwater
Jenniea Olalia
2025-01-07T15:16:12-07:00
Stillwater
Underwriting Questionnaire
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Which Policies do you have?
Home
Auto
Landlord / Dwelling Fire
Umbrella
Home Questionnaire
You are advised there may be an inspection to verify the condition and pride of ownership of the dwelling, detached structure(s) and premises and to confirm the answers to the following underwriting questions.
(Required)
Select One
No
Yes
How old is the roof?
Is there any pre-existing damage to the home? This includes, but is not limited to, exterior wall damage, excessive peeling paint, damaged soffits or fascia, broken windows or doors, chimney damage, etc.
(Required)
Select One
No
Yes
Is any unit in the structure occupied by more than 1 family?
(Required)
Select One
No
Yes
Is the roof in good condition without any known damage, deterioration, missing shingles, excessive granular loss, raised or lifting shingles, and is there only one layer of shingles on the roof?
(Required)
Select One
No
Yes
Does the Dwelling have a plumbing system that utilizes Polybutylene piping materials?
(Required)
Select One
No
Yes
Is there a solid fuel burning appliance present (e.g. wood burning stove)? This would include stoves, fireplace inserts, or similar devices that burn wood, pellets, or other solid fuels. Note: Built in Fireplaces that have a metal or masonry chimney are not considered to be a Solid Fuel Burning Appliance.
(Required)
Select One
No
Yes
Does the occupant of the dwelling own an animal or plan on acquiring one in the next 12 months?
(Required)
Select One
No
Yes
Is there a fire hydrant within 1000 ft. of the residence?
(Required)
Select One
No
Yes
Is there a responding Fire Department within 5 road miles of the residence? If the Fire Department requires a subscription, do you agree to maintain the subscription while insured under this policy?
(Required)
Select One
No
Yes
Is the dwelling located within 400 ft. of brush area, forested area or any area of increased fire hazard?
(Required)
Select One
No
Yes
Is this dwelling vacant (If New Purchase to be occupied within 60 days after purchase, select NO)?
(Required)
Select One
No
Yes
Does the dwelling have unusual or irreplaceable construction, cantilever construction, including dwelling on posts, stilts or pilings (except where the result is required or authorized by current buildings codes to be elevated on posts/piers/pilings and there is no slope/stilts), or is a log, mobile, manufactured, modular or metal home, or utilizes asbestos siding/roofing?
(Required)
Select One
No
Yes
Are any abandoned, non-operational, not regularly used, or commercial vehicles stored at this location, or any vehicles parked off the driveway or normal parking areas?
(Required)
Select One
No
Yes
Is there a business conducted on the property that is not insured under a separate business owners policy issued by Stillwater?
(Required)
Select One
No
Yes
Are there any swimming pools on the property?
(Required)
Select One
No
Yes
Are all swimming pools on the property fully enclosed?
(Required)
Select One
No
Yes
Is there a pool that is either unfenced, unfilled or unmaintained?
(Required)
Select One
No
Yes
Is there a pool that is either unfenced, unfilled or unmaintained?
(Required)
Select One
Diving Board Only
Slide Only
Diving Board and Slide
No Diving Board or Slie
In the past 60 months, has the applicant had any losses?
(Required)
Select One
No
Yes
How many Liability Related Losses?
(Required)
Select One
0
1
2
3+
How many Water Related Losses?
(Required)
Select One
0
1
2
3+
How many Weather Related Losses?
(Required)
Select One
0
1
2
3+
How many Other Losses?
(Required)
Select One
0
1
2
3+
Are there any above ground trampolines at this location that DO NOT meet BOTH of the following requirements: 1) located in a fenced portion of the yard; AND 2) equipped with a properly installed safety net? Or, are there any in-ground trampolines at this location that are not located in a fenced portion of the yard?
(Required)
Select One
No
Yes
Is the risk location used for farming or ranching activity which would include but not be limited to the storage of equipment used for farming or ranching?
(Required)
Select One
No
Yes
Auto Questionnaire
Landlord / Dwelling Fire Questionnaire
Umbrella Questionnaire
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Admin Use Only
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Form Category
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Form Name
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Agency Name
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AMS ID
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CRM ID
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Internal Use
Yes
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