AARP Homeowners Insurance Questionnaire

(FIRE, EXTENDED COVERAGE, V&MM, EARTHQUAKE AND LIABILITY)

(DOES NOT INCLUDE FLOOD)

(Versión Español)

Full Name

AARP Member ID

Mailing Address

Occupation:

Policy Period:

E-mail:

Fax:

Home Telephone:

Cellular Telephone:

Business Telephone:

Physical Address of property to be insured:

Name of company currently insuring property:

Number of current or previous policy:

Expiration Date:

(mm/dd/yyyy)

Mortgagee Name and Address:

Loan Number:

Section I - PROPERTY- Please provide values below as requested

Year Built (Mandatory):

Building: $

Other Structures: $

Contents: $

Loss of use: $

Additional Coverage

Permission to Rent:

Yes

Structures rented to others limit: $

Scheduled Personal Property: $

If replacement value of the real property (Structure) is $500,000 or more, you will need a copy of recent appraisal with photographs so we may be able to offer a quote.

If residence is a condominium or townhouse, amount of building additions and alterations (Also known as improvements) needed if not covered under the association master policy $:

Type of Construction

Roof::

Concrete Tile Wood Shingles	Wood Metal Carton	Silicone Hypalon Gable Roof
Other - Describe:
Hip Roof	Length of overhang:

Exterior Walls::

Concrete Concrete Block Steel/Wood

Metal Wood

Stone Brick

Floor::

Concrete Concrete/Steel Other

Metal Wood

Stone Brick

Protection Devices (Recent photograph of building must be submitted)

Hurricane Shutters:

None Fixed Aluminum Wood Roll Down Accordion Other

(Louvres or iron bars are not considered hurricane shutters)

Deductibles

Windstorm and Earthquake:

3% of amount insured 5% of amount insured

Other Perils: $

$1,000 $2,500

Owner Occupied:

Yes No

Number of families:

Seasonal or Non-Seasonal:

Seasonal Non Seasonal

Is this a duplex?:

Yes No

Do you own both units/the entire building?:

Yes No

If seasonal, how many consecutive months do you occupy the residence:

Who takes care of the property in your absence?:

Is it rented to others?:

Yes No

Long term rental?:

Yes No

If rented long term, how many consecutive months:

Short term rental?:

Yes No

If rented short term, how many consecutive months:

Vacant?:

Yes No

We are unable to offer coverages for vacant buildings or short term rentals.

We are unable to quote homeowners for residences with more than two families.

If this is a three or four family residential structure owned by you, we can offer a dwelling quote.

Please check one of the following, if applicable, to receive a dwelling quote to cover the structure:

Three family (Your personal residence plus two apts.)

Four family (Your personal residence plus three apts.)

Not applicable

HOWEVER, WE ARE UNABLE TO OFFER A DWELLING OR HOMEOWNER QUOTE TO COVER THE STRUCTURE IF:

• RESIDENCE IS OCCUPIED OR AVAILABLE FOR MORE THAN FOUR FAMILIES INCLUDING YOUR PERSONAL RESIDENCE

• RESIDENCE IS A CONDOMINIUM OR TOWNHOUSE UNIT (THIS IS MORE ADEQUATELY COVERED UNDER A MASTER POLICY IN THE NAME OF THE ASSOCIATION)

• RESIDENCE IS INDIVIDUALLY OWNED BUT IS PART OF A DUPLEX BUILDING WHICH IS NOT OWNED IN ITS ENTIRETY BY YOU

THERE ARE LIMITATIONS ON CERTAIN ITEMS. ONE BEING JEWELRY WHICH HAS A LIMIT OF $1,000.  IF YOU WISH TO INCREASE THE LIMIT FOR SOME OF THESE ITEMS, PLEASE PROVIDE AN ITEMIZED SCHEDULE WITH VALUES AND APPLRAISALS AND CHECK OFF SCHEDULED PERSONAL PROPERTY IN THE BOX INDICATED.

NO PROPERTY COVERAGE AFFORDED FOR OUTDOOR SWIMMING POOL OR ANY STRUCTURE OR PROPERTY SET ASIDE FROM THE MAIN DWELLING WHETHER OR NOT CONNECTED BY A FENCE, UTILITY LINE OR SIMILAR CONNECTION OR CONCRETE PATIO, UNLESS A SUM INSURED LIMIT IS ENTERED FOR OTHER STRUCTURES IN THE CORRESPONDING SPACE PROVIDED.

THE HOMEOWNERS POLICY INCLUDES A COINSURANCE CLAUSE WHICH STATES YOU MUST INSURE AT LEAST 80% OF THE REPLACEMENT COST OF THE STRUCTURES TO AVOID A PENALTY IN THE EVENT OF A LOSS.

Section II - PERSONAL LIABILITY

Please check off one of these options:

I only wish $25,000 included on the policy (Basic limit $25,000 with $1,000 medical payments included)

I wish to increase limit to $100,000

I wish to increase limit to $300,000

Swimming Pool:

Yes No

Is pool fenced?:

Yes No

Additional residence in building:

None

One apartments rented to others

Two apts. rented to others

Three apts. rented to others

One family residence in separate bldg on same premises

TWO family residence in separate bldg on same premises

----------------

Rental

NON-RENTAL

----------------

DUPLEX. BOTH SIDES OWNED BY YOU

YOU OCCUPY ONE SIDE AND RENT OUT THE OTHER

YOU RENT OUT BOTH SIDES

One family residence AWAY FROM PREMISES

TWO family residence AWAY FROM PREMISES

----------------

Rental

NON-RENTAL

Located at:

Permitted incidental occupancies:

(small office or studio in home)

Losses last 3 years:

Yes No

WindstormEarthquake Theft

FireLiability Other  N/A

Amount of loss :$

Date of loss:

(mm/dd/yyyy)

Real Legacy Assurance Company, Inc.
P.O.Box 71467 San Juan, P.R. 00936-8567	Metro Office Park Calle 1 Lote 4 Guaynabo, P.R. 00968

Subsidiary of

2006 ® Real Legacy Assurance. All rights reserved.