| Personal Information |
| Insured Name (First, MI, Last) | |
| Mailing Address | |
| City | |
| State | |
| Zip Code | |
| Phone# | |
| E-mail Address | |
| Date of Birth (DD/MM/YYYY) | |
| Marital Status | |
| Spouse's Name (First, MI, Last) | |
| Date of Birth (DD/MM/YYYY) | |
| Does Anyone Smoke? | YesNo |
| County Property is Located | |
| Property Address (if different from Mailing Address) | |
| City | |
| State | |
| Zip Code | |
| Have you had a bankruptcy or judgement against you in the last 5 years? | Yes |
| Farm Information |
| Type of Farm | |
| Livestock # | If "Other" specify |
| Number of Farm Locations | |
| Location #1 | # of Acres # of Farm Residences |
| List any other locations including address & # of acres | |
| Total Value of Barns and Other Farm Buildings | |
| Total Value of Farm Personal Property | |
| Farm Property Deductible | |
| Farm Liability | |
| Farm Medical Payments | |
| Number of Employees | Full Time Part Time |
| Current Home Insurance |
| Current Insurance Company | |
| Policy Term | |
| How Long with Current Company? | |
| Renewal Date (DD/MM/YYYY) | |
| Policy Premium | |
| Is it a House or Mobile Home? | |
| Do currently have Auto Insurance? | YesNo |
| Current Insurance Company | |
| How did you hear of us? | |
| Current Insurance Coverage |
| Dwelling Coverage | |
| Other Structures | |
| Personal Property | |
| Loss of Use | |
| Liability | |
| Medical Payments | |
| Policy Deductible | |
| Home Information |
| Home Use | |
| Year House/Mobile Home was Built | |
| What Type of Structure is Home? | |
| How Many Stories? | |
| Total House Square Footage | |
| Type of Foundation Home Set On | |
| Year Electrical put in/Updated (Note Electric Must be 100amps or Higher & on Breakers to Qualify!) | 100Amps or Higher? YesNo |
| |
| Year Heating put in/Updated | |
| Year Roof put on/Replaced | |
| Year Siding put on/Replaced | |
| Do you have a garage? If so what Type. | |
| Are there any other structures? | YesNo |
| Primary Fire Dept | |
| How far from Fire Dept? | |
| Are you within city limits & within 1,000ft of a fire hydant? | YesNo |
| Primary Type of Heat | |
| Secondary Type of Heat (if applicable) | |
| House and Property Features (Check all that apply) | Swimming Pool Trampoline
Smoke Detectors Fire Extinguishers
Carbon Monoxide Det Dead Bolts
Central Station Fire Alarm
Central Station Burglar Alarm
Visible to 3 or More Neighbors |
| How much land do you own? | |
| Any home business or daycare? | YesNo |
| Do you have any pets? (If so what are they) | |
| Any recreational vehicles or boats? | YesNo |
| Any expensive jewelry, furs, art, collectibles, antiques or guns to schedule? | YesNo |
| Do you own a seasonal home, rental property or vacant land? | YesNo |
| Are you interested in Flood or Earthquake coverage? | YesNo |
| Claim History |
List all claims in the past 3 years (include date, amount paid & what type of claim)
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| Type of Claim | Date of Claim Occurance | Amount Paid on Claim |
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| Additional Comments |
Please give any additional comments that are appropriate for this quote. |
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