Home Health Checkup - Hello Covered

First name*

Last name

HVAC

What type of cooling does the home use?*

How many AC units does the home have?

Model

When was it installed?

Most recent service

List major repair(s)

Model (unit #2)

Install date (unit 2)

Most recent service (unit 2)

List major repairs (unit #2)

Model (unit #3)

Install date (unit 3)

Most recent service (unit 3)

List major repairs (unit #3)

Model (unit #4)

Install date (unit 4)

Most recent service (unit 4)

List major repairs (unit #4)

What type of heating does the home use?*

How many heating units does the home have?

Model

When was it installed?

Most recent service

List major repair(s)

Model (unit #2)

Install date (unit 2)

Most recent service (unit 2)

List major repairs (unit #2)

Model (unit #3)

Install date (unit 3)

Most recent service (unit 3)

Electrical

Number of electrical panels*

Please enter a number from 1 to 9.

Total amperage

Most recent panel upgrade

Most recent repair

Please add your address so we can automatically get details about your home, like square footage and year built.

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Water and Plumbing

Select type of water heater

When was it installed?

Where is your water heater located?

Do you have a pool?

What type of pool do you have?

When was it installed?

Most recent filter cleaning

Are there signs of seepage (wet spots or moisture) in the home, basement or attic?

Describe the issue(s)

Are rain gutters installed on the home?

Do the gutters overflow when it rains?

Foundation

What type of foundation does the home have?*

Have you noticed cracks in walls or other signs of foundation damage?

List major foundation repairs

Roof

What type of roof is installed?*

When was your roof installed?

List major roof repair(s)

Safety

How many smoke alarms are in the home?*

How many carbon monoxide alarms are in the home?

When was the last time these alarms were tested?

Is the home equipped with a security system?*

When was the last time the security system was tested?

When was the last time the windows were replaced?*

Is there a fireplace in the home?*

When was the last time the fireplace was used?

Does the home have natural gas service?*

When was your clothes dryer purchased?

Are there any signs of mold, pests or rodents?

Mold and signs of rodents are most often found in the attic, bathrooms and crawlspace or basement.

Where should we deliver your report?

We will review this information to create your home health check up and make personalized recommendations. Where should we send this report?

Phone number*

Email address*

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