First
name*
MI
Last
name*
Address
*
City*
State*
Select
MO
IL
Zip*
Marital
Status
Select
Single
Married
Divorced
Widowed
Other
Best
way to be contacted?*
Select
e-mail
phone call
letter
fax
Phone
number (add area code)*
Best
time to call*
a.m.
p.m.
Fax
number
Work
number
E-mail
address *
Occupation
How
long
Select
Years
Months
Additional
Comments:
Home
Information
Policy
type
Select
Primary
Secondary
Dwelling
type
Select
1 Story
Ranch
Bi-Level
2-Story
Tri-Level
Duplex
Rental unit
Vacant property
Other
Garage
Type
Garage Type
No garage
Carport
Attached 1 car garage
Attached 2 car garage
Attached 3 car garage
Unattached 1 car garage
Unattached 2 car garage
Unattached 3 car garage
Other
#
of units
#
of stories
Year
built
Construction
Select
60% or more brick
60% or more frame
Stucco
Cinder Block
Log
Other
Basement
Select
No basement
Unfinished basement
Partly finished
Fully finished
Other
Total
square feet
Total square feet first floor
Total square feetwithout basement
Foundation
Type
of roof
Plumbing
Electrical
system
Central
alarm
Select
Yes
No
Heating
Updated
Central
Air
Select
Yes
No
#
of fireplaces
#
of bathrooms
Size
of deck(s)
Swimming
pool
Select
Yes
No
Bush
Area
Yes
or No to items that are part of the residence.
Dead
bolts
Select
Yes
No
Fire
Extinguisher
Select
Yes
No
Smoke
detectors
Select
Yes
No
Covered
patio/deck
Select
Yes
No
Uncovered
patio/deck
Select
Yes
No
Swimming
pool
Select
Yes
No
Wood
Stove
Select
Yes
No
Central
Alarm System
Select
Yes
No
If
this quote if being prepared for a new home, please enter the
closing month and year
(mm/yyyy)
Mortgage
Protection
In
the event that one of the principal owners die, would you like
to have the mortgage paid? If YES, please provide answers to
the questions below, otherwise please continue on.
Approximate
amount to pay off mortgage $
Approximate
number of years left to pay on your mortgage
Claims/Losses
(if NO losses or claims, please skip to the next section)
Please
enter information on the 3 most recent claims/losses in the
past 3 years.
Insurance Information
Are
you now, or have you been insured within the past 30 days?
Select
Yes
No
If
Insured, please indicate insurance carrier
Expiration
date
Approx.
how long have you been insured with your current carrier?
Select
Less than 1 month
Less than 3 months
Less than 6 months
Less than 1 year
Less than 2 years
Less than 3 years
Less than 4 years
Less than 5 years
Less than 10 years
Over 10 years
How
long have you been continuously insured?
Select
Less than 1 month
Less than 3 months
Less than 6 months
Less than 1 year
Less than 2 years
Less than 3 years
Less than 4 years
Less than 5 years
Less than 10 years
Over 10 years
Do
you want earthquake insurance?
Select
Yes
No
Would
you like a scheduled property coverage?
Select
Yes
No
Would
you like to add anything to the policy as a rider? (i.e.
wedding rings)
Other
Information
