2. Mail Address

3. Street Address if different

4. City

5. State

6. Zip

7. Area Code and Home Phone

8. Area Code and Work Phone/Ext.

9. Area Code and FAX

10. Email

11. Contact us Morning Afternoon Evenings

12. Select the type of policy you would like a quote on Homeowners Renter/Tenants Condo Dwelling Fire

13. Current Residence Status Own Rent Other

14. Is this a primary or secondary home? (choose one) Primary Secondary Rental Property

15. Do you need special coverage for jewerly, fine art, antiques, silverware, furs, computers, or other items? Yes No
a. If yes to #15, please list items and approximate value

16. If insured, list name of company insured with

If a rentor, skip to question #20

17. Homeowners or Condo (coverage A on existing policy) Amount of coverage on dwelling: (i.e. $150,000) - $

18. Personal Property (coverage C on existing policy) Amount of coverage on personal property (i.e. $25,000 - Minimum of $15,000)

19. Personal Liability (coverage E on existing policy) $300,000 $500,000 $1,000,000

20. Deductible Amount $250.00 $500.00 $1,000.00 $2,000.00

21. Construction Type Wood Frame Other

22. Approximate year residence was built (i.e. 1977)

23. Type of Heat Oil Gas Electric Other

24. Check all that apply

Smoke Detectors
Swimming Pool		If Yes, Diving board? Yes No	Fenced? Yes No
Central Burglar/Fire Alarm
Trampoline
Dogs or Horses		If Yes, name breed
Wood, Coal, Pellet Stove

25. Any business conducted on premises? Yes No
If yes, please describe

Claims/Loss Information

26. Please describe any claims or losses you've had in the past 3 years.

27. Discount Information
Most insurance companies provide a 10% discount on your homeowners policy if you insure your vehicles and residence with them.
Would you be interested in this discount? Yes No

28. Questions and/or Comments