Full Name:

Street Address:

City, State & Zip:

E-Mail Address:

Day Telephone:

Fax:

Eve Telephone:

Best Time To Reach You:

Select Mornings Afternoons Evenings Weekends Anytime

Date of Birth:

Insurance Company Name:
(NOT Insurance Agency/Broker)

Policy Exp. Date:

Amount Insured for:

Premium Amt:

Any Claims in Last 3 years?

Year Home Built:

Total Square Feet:

Yrs @ present address: Market Value of Home: $

Liability Coverage:

Please Select $100,000 $300,000 $500,000 $1,000,000 Other

Deductible Desired:

Please Select $250 $500 $1000 $2500 $5000

Distance to nearest fire hydrant: Please select Less than 1,000 ft More than 1,000 ft

Distance to nearest fire department: Please select Less than 5 miles More than 5 miles

Name of Responding Fire Dept:

Home Type:

Select 1 story 1 1/2 story 2 story Split level Bi-Level Other

Home Construction:

Select Frame Brick Masonry Other

Roof Type:

Garage Type:

Select 1 car 2 car 3 car Car Port Other

Age of roof:

Garage:

Select Attached Detached Basement Other

# of Bedrooms:

# of Fireplaces:

# of Bathrooms:

Exterior:

Select Deck Porch Patio Screen Patio

Foundation:

Select Slab Crawl Basement Pier & Post Not Sure Other List in Comments

Basement Finished?

No Yes

Number of Acres:

If finished, what %?

%

Type of Farming Operation:
Total Acres by Crop:	Crop Acres
Amount of Insurance on all Farm Buildings (including silos):
Amount of Insurance on Farm Equipment and Machinery (include tractors, milk equipment, crop dryer, etc...)
Amount of Insurance on all Livestock:
Annual Revenues from Custom Farm Work:
Number of Horses:
Number of Cows:

Swimming Pool?: No Yes

Pool Fenced: No Yes

Diving Board: No Yes

Trampoline: No Yes

Smoke Detector: No Yes

Security System: None Monitored Non-Monitored

Heating System: Select Electric Gas Oil Propane Other

Heated Sq. Ft.

Central Air/Heat: Select Yes No

Updates: (check all that apply)
Wiring updated
Plumbing updated
Heating updated

Fire Alarm:

None Monitored Non-Monitored

Replacement cost of personal items:

Any business conducted in home:

List values of any jewelry, furs, or specialty items:

List pets & breeds:

Do you want to include a Flood Insurance Quote?: No Yes

Please give any additional comments or questions