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AllMass / Fernekees Insurance Agency
PROTECT YOUR HOME FOR THE VALUE IT HOLDS 
  
  We would appreciate it if you would take a few moments to answer the following questions. Please be assured that we do not share or sell personal information about you except when we have your permission.     
     
     
         
     
First Name M.I. Last Name
  Property Address City State Zip Code  
   
  Mail Address (if different) City State Zip Code  
   
 

E-mail Address

  
     
 

BUILDING INFORMATION

  
       
Year Built: Number of Families: 1- Family   2- Family   3- Family
       
  Style:
What is the total square footage of the living area?
      
(If unknown this can be determined by the lenght x height x stories.)
       

Is there a basement?

 Yes  No  
 

What percentage of it is finished, if any?

  
       
  What material is the roof?  
Example - Asphault Composition
       
       
  What kind of Exterior Walls does your home have?    
     
  (Ctrl + Click to highlight multiple selections)    
  If more than one applies, pleas provide a percentage breakdown here:    
  Breakdown must equal 100%    
       
  What do the Interior Walls consist of?        
                 
  (Ctrl + Click to highlight multiple selections)                
  If more than one applies, pleas provide a percentage breakdown here:                
  Breakdown must equal 100%                
 

 		    

 		          
                   
  How are the Interior Walls Finished?     What materials do the Ceilings consist of?          
               
  (Ctrl + Click to highlight multiple selections)     (Ctrl + Click to highlight multiple selections)          
  If more than one applies, pleas provide a percentage breakdown here:     If more than one applies, pleas provide a percentage breakdown here:          
  Breakdown must equal 100%     Breakdown must equal 100%          
 

 		    

 		          
                   
  Are any of the following present in your home?     How are the floors finished?          
 

 		    

 		          
  (Ctrl + Click to highlight multiple selections)     (Ctrl + Click to highlight multiple selections)          
  Of the items chosen, how many of each are present?     If more than one applies, pleas provide a percentage breakdown here:          

 		 Breakdown must equal 100%
                   
                   
                   
                   
  How many kitchens are in your home?              
                   
  Have you done any custom remodeling in your kitchen(s)?`                
                   
  If yes, please describe:              
                   
How many bathrooms? Full Half Three-quarters  
                   
  What is the primary source of heat?              
  if oil. where is tank located?              
  Secondary heat source (if any)              
  When was the heat renovated?              
                     
  Does your home have central air conditioning? Yes  No                
  If yes, does it share the ducts with the heating system? Yes  No                
                   
  How Many Fireplaces? Wood Burning Gas Outdoor kiva / fire pit      
                   
 

OTHER STRUCTURES

                
                   
  Does your home have a : Deck     Sq. Ft. Type      
      Porch Sq. Ft. Type    
      Breezeway Sq. Ft. Type    
                   
  Is there a shed in your yard? Yes  No   If yes, is it small, medium, or large?            
           
     
  Do you have a pool? Yes  No   If yes, is it small, medium, or large?            
                 
                 
  Do you have a hot tub / jacuzzi? Yes  No   If yes, is it small, medium, or large?          
           
     
  Is there a garage? Yes  No   If yes, how many cars?            
                 
 

RATING INFORMATION

                
  Do you have a mortgage? Yes  No   If yes, what is the balance?          
                 
  What year did you purchase the house?              
                   
  What condition is the house in?              
                   
  What type of electrical system do you have? Circuit Breakers  Fuses            
  What is the AMPS?              
                   
  What condition is the plumbing system in?              
  Any known leaks? Yes  No                
  When was the plumbing system last renovated?              
  To what extent was the renovation Complete Partial               
                   
  When was the roof last updated?
Any known leaks?
 Yes No            
                   
  Do You own any pets? Yes  No   If yes, please indicate type(s) and breed(s)            
                 
  Within the past three years, have you had any insurance claims? Yes No              
  If yes, please indicate the type(s) of losses, and amount paid by the insurance company:                
 

 		                
                   
  Have you been declined, cancelled, or non-renewed insurance in the past three years?    Yes  No              
                   
  If yes, please explain:                
                 
                   
                   
  If you are already insured with us please let us know who your agent is, so we can direct your submission accordingly?                
                 
                   
  How did you hear about us?