Home Update Questionnaire Home » Request Policy Change » Home Update Questionnaire Requestor Information First Name:* Last Name:* Email Address:* Phone Number:* Home Location Street Address:* City:* County:* State:* —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code:* Roof Roof Material:* —Please choose an option—AsbestosFiberglassWood Shingles/ShakesTinCopperTileSlateAsphalt Composite Age of Roof:* Warranty of surface material, in years: —Please choose an option—1234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950 Condition of Roof:* —Please choose an option—Needs WorkExcellentGoodFair Additional Roofing Comments: Plumbing Pipes made of: —Please choose an option—OtherCopper Inside/PVC OutPVC PlasticGalvanized IronCopper How old is the plumbing or in what year was it last updated?* Was the work performed by a licensed plumbing contractor? YesNo Please describe the extent of the plumbing work completed: Additional Plumbing Comments: Electrical Please check all that apply to your electrical system* Circuit BreakersFuse BoxConduitRomexBX Cable Amperage Rating:* —Please choose an option—More than 20020010060 How old is the electrical system or in what year was it last updated?* Was the work performed by a licensed electrical contractor? YesNo Please describe the extent of the electrical work completed: Other Electrical Comments: Heating and Cooling System Type of Heating/Cooling System* —Please choose an option—OtherElectricSteamHot WaterForced Air Please indicate oil tank location How old is the heating system or in what year was it last updated? Is it serviced annually?* YesNo Date last serviced:* MM010203040506070809101112DD01020304050607080910111213141516171819202122232425262728293031YYYY2021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910 Is there a secondary or supplemental heat source?* YesNo If yes, was it professionally installed? YesNo Is it cleaned or serviced annually? YesNo Type of Hot Water Heater:* —Please choose an option—OtherGasElectric When was it installed?* MM010203040506070809101112DD01020304050607080910111213141516171819202122232425262728293031YYYY2021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910 Other Heating and Cooling Comments or Questions: Additional Heating and Cooling Comments or Questions Binding Agreement* (Required) I understand that any policy changes and quote requests are effective only when I have received a written confirmation Age of all items should refer to years old or year installed. Client Services File a Claim Request a Certificate Request ID Request Policy Change Get a Quote