Scott Schultz – Lakeview Insurance
Scott Schultz – Lakeview Insurance
Protecting What Matters Most
Homeowner's Questionnaire
01/15/2026
Name
*
BirthDay:
*
Phone
*
Name
*
BirthDay:
*
Phone
*
Mailing Address:
*
Email Address:
*
Physical Address:
*
Possession Date:
*
Are you a first time home owner?
*
Yes
No
Lawyer Information:
*
Mortgage Information:
*
Previous Address:
*
Previous Insurance Company:
*
Policy Number:
*
Expiry Date:
*
How many years continuously insured for?
*
Referred by?
*
Any claims within the past 5 years?
*
Yes
No
If yes please explain:
Do you consent to credit scoring for a possible discount?
*
Yes
No
Home Info:
Year Built:
*
Square Feet:
*
Style of House
*
1 Story
2 Story
Bi-Level
Other Name:
Bathrooms - How Many?
Full:
0
1
2
3
4
5
6
7
8
9
10
3/4:
0
1
2
3
4
5
6
7
8
9
10
Half:
0
1
2
3
4
5
6
7
8
9
10
Other:
0
1
2
3
4
5
6
7
8
9
10
Custom Bathrooms:
0
1
2
3
4
5
6
7
8
9
10
Kitchens:
How Many?
1
2
3
Customer Cabinets:
Yes
No
Custom Counter Tops:
Yes
No
Roof:
Year Updated
*
% Asphalt Shingles:
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Tin:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Other:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
Other Name:
Foundation Type:
% Basement:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Walk out:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Crawl Space:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Slab:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Finished Basement:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
Foundation Material:
% Concrete:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Wood:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Other:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
Other Name:
Wall Height:
% 8':
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% 9':
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Vaulted:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Other:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
Other Name:
Interior Walls:
% Drywall:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Other:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
Other Name:
Wall Coverings:
% Paint:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Other:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
Other Name:
Ceiling Material:
% Drywall:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Plaster:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Other:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
Other Name:
Flooring:
% Hardwood:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Laminate:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Carpet:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Vinyl:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Ceramic Tile:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Other:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
Other Name:
Heating:
Year Updated:
*
% Natural Gas:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Electric:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% In Floor Heat:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Oil:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Propane:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Other:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
Other Heating Name:
% Air Conditioner:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
Any Fire Places?
Gas:
Yes
No
Insert:
Yes
No
Wood Stove:
Yes
No
Electrical:
Year Updated:
*
% Copper:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Aluminium:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
100 Amp:
Yes
No
200 Amp:
Yes
No
Other:
Plumbing:
Year Updated:
*
% Copper:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Plastic:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Other:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
Other Name:
Sump Pump/Pit?
Yes
No
Back Water Valve?
Yes
No
Exterior Siding:
% Vinyl:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Stucco:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Wood:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Hardy Board:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Stone:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
% Brick:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
Other Name:
Attached/Detached Garage
Attached Garage
1 Car
2 Car
None
Attached SQ Ft:
*
Detached Garage
1 Car
2 Car
None
Detached SQ Ft:
*
Other:
Attached Structures:
Wood Deck SQ Ft:
Composite Deck SQ Ft:
Deck Roof Cover SQ Ft:
Porch:
None
Open
Closed
Screened Porch SQ Ft:
Breezeway:
None
Open
Closed
Solar Room:
Yes
No
Other:
Is there and Addition?
Year Built:
Number of Stories:
0
1
2
Square Feet:
Foundation Type:
Exterior Siding:
If Any - Number of:
Interior Doors:
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Exterior Wood Door:
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Exterior Steel Door:
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Patio Doors:
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
French Doors:
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Sliding Glass Doors:
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Skylights:
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Picture WIndows:
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Bay WIndows:
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Jacuzzi Tub:
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Hot Tub:
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Pool(Indoor/Outdoor):
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Wet Bar:
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Extra Kitchen:
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Central Vac System:
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Central Alarm System:
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Central Fire Alarm:
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Home Base Business:
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
ATV:
0
1
2
3
4
5
Boat:
0
1
2
3
Other:
0
1
2
3
4
5
6
7
8
9
10
Other Name:
Any High Valued Jewelry:
Yes
No
Fire Access
Distance to Nearest Fire Hall:
*
Fire Hydrants
*
Yes
No
Notes/Comments:
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