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:
Information on address being quoted
Type
of insurance needed
Select
Tenant
Renters
Design
of the property
Select
Apartment
Condominium
Townhouse
Duplex
House
Other
Street
address
City
State
Select
MO
IL
Zip
Deductible
Select
100.00
250.00
500.00
1,000.00
2,000.00
Amount
of coverage for Personal Property
$
Approximate
size of residence
Total
square feet 1st floor
Total
square feet without basement
Year
residence was 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
Garage
Type
Select
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
Fire
Station
Select
Within 5 miles
Within 10 miles
More than 10 miles
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
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
