Boizelle Insurance Partnership - Free Online Quote Request and Personalized Insurance Service in MD, VA, DC

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301-948-2010 301-948-4777 800-783-2421

PERSONAL CATASTROPHE LIABILITY
RENEWAL QUESTIONNAIRE

Your Name

1. List all policies owned - excluding Life Insurance

POLICY NUMBER COMPANY LIMITS OF LIABILITY

HOME

ADDITIONAL DWELLING

AUTO

OTHER

2. List all personal use automobiles and recreational motor vehicles subject to motor vehicle registration.

YEAR/MANUFACTURER MODEL OWNED RENTED, OR FURNISHED

1

2

3

4

3. Please answer the following questions. Include information on all underlying insurance (Type of Policy, Policy Number, Company, and Limits of Liability).

A. Do you own any dwelling and/or farms, which are rented to others, maintained as residences, or vacant?	Yes No
If YES show the number of families location(s), and underlying policy information.

B. Do you have any recreational motor vehicles not subject to motor vehicle registration (Examples snowmobile, ATV's dirt bikes)?	Yes No
If YES - how many and what type are they?

C. Are you or any member of your household insured as Assigned Risk or High Risk Plan? ..	Yes No

D. Are you or any member of your household an excluded driver on any automobile policies?	Yes No

E. Is any business being conducted from your premise?	Yes No
If YES - what type of business?

F. Is any member of your household a youthful driver (under 24)?	Yes No
If YES please list name(s) and birth date(s)

G. Do you own or regularly use any watercraft?	Yes No
If YES please describe type (inboard, outboard or sail), length, maximum speed, and horsepower.
Addition Information/Comments

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NOTICE OF LICENSURE

Boizelle Insurance Partnership, Inc. is licensed to conduct business in District of
Columbia, Maryland, Virginia, North Carolina, Pennsylvania and West Virginia. The
information on this site is a solicitation to conduct business only in the following
state of authority: Maryland, Virginia and District of Columbia.

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