Homeowners/Renters/Automobile Questionnaire
Email address *
SunGolde Insurance
Today's Date
MM
/
DD
/
YYYY
Effective Date (Renewal Date)
MM
/
DD
/
YYYY
Insured Name (first and Last)/Co-Applicant Name(s)
Your answer
Street Address
Your answer
City, State, Zip Code
Your answer
Phone Number
Your answer
Insured Date of Birth
MM
/
DD
/
YYYY
Co-Applicant Date of Birth
MM
/
DD
/
YYYY
Highest Education
Highest Education Co-Applicant
If at current address less than 1 year, please provide previous address
Your answer
Limit for Dwelling (home) Coverage
Your answer
Renters Coverage - Contents Limit
Your answer
Limit for Liability Coverage
Your answer
Limit for Medical Coverage
Your answer
Basement (Y/N) - If yes, finished (Y/N)
Your answer
Sump pump coverage
Year home built
MM
/
DD
/
YYYY
Purchase Date
MM
/
DD
/
YYYY
Purchase Price
Your answer
Square Footage
Your answer
Architectural Style
Additional Info
1
2
3
4
5
Number of Stories
Number of Bathrooms
Number of Bedrooms
Garage
Number of Families
Foundation Type
Roof Type
Year Roof Updated
MM
/
DD
/
YYYY
Heat Type
Year Heat Updated
MM
/
DD
/
YYYY
Dogs/Exotic Animals on Premises
Current Carrier/Homeowners
Annual Premium/Homeowners
Your answer
Additional Information
Your answer
Current Carrier/Automobile
Vehicle Info: (Please provide year, make, model and VIN for each household vehicle to be insured)
Your answer
Vehicle List (For each household vehicle please provide the following): Year Make Model VIN *
Your answer
Household Driver Information (For each household driver please provide the following): Name Date of Birth Drivers license number Issuing state
Your answer
Incidents (At-Fault accidents/moving violations for each household driver for the past 5 years)
Your answer
Policy Liability Limits
Deductibles - Collision
Deductibles - Comprehensive
Towing
Rental Reimbursement
Good Student Discount (If applicable)
Defensive Driver Discount (If applicable/please provide certificate of completion)
Annual Premium/Automobile
Your answer
Additional Information
Your answer
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