Contact Information

Name
Address
City, State ZIP
Phone
E-Mail
FAX

Applicant Information

First Name

Last Name

Birth Date

Social Security #

Residence Information

How is this residence used?	select one of these ................... primary residence secondary or seasonal children or parents live here house is rented to others house is for sale house is vacant
List the street address of the      house if different from the      address above.

Coverage Amounts
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House     $	Contents     $	Other Structures     $
Personal Liability      select one .... $100,000 $300,000 $500,000 $1,000,000	Medical Payments      select one .... $1,000 $2,000 $3,000 $4,000 $5,000	Deductible      select one .... $250 $500 $1,000

Scheduled Personal Property
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Jewelry	$	Watercraft	$
Computer Equipment	$	Snowmobile / ATV	$
Firearms / Guns	$	Antiques	$
Fine Arts	$	Other Collectibles	$

Year Built	Square Feet	Number of Stories   select one ........ 1 story 1 1/2 stories 2 full stories bi-level	Construction Type   select one ........ wood frame masonry mobile home modular home
Foundation   select one ........ basement crawl space cement slab tie downs on blocks	Age of Shingles   select one ........ 0-5 years old 6-10 years old 11-15 years old 16-20 years old 21-30 years old > 30 years old	Wiring Updated   select one ........ in last 10 years in last 20 years in last 30 years not recently	Heating Updated   select one ........ in last 10 years in last 20 years in last 30 years not recently

How many road miles is the house from a    responding fire department?	select one ............. 1 mile 2 miles 3 miles 4 miles 5 miles over 5 miles
How many feet is the house away from a    fire hydrant?	select one ............. less than 1,000 ft more than 1,000 ft

Explain all "yes" answers in the space below.
Is there any business conducted at this residence?    (example: daycare, incidental office, etc.)	yes     no
Do you own any watercraft, snowmobiles, or all-    terrain vehicles?  (List type and HP or CC's.)	yes     no
Do you have a wood stove or wood-burning     fireplace?	yes     no
Do you have smoke detectors, burglar alarms, or     an automatic sprinkler system?	yes     no
Do you have a dog? If yes, list the number of dogs     and their breeds.	yes     no
Do you have a trampoline or swimming pool?	yes     no

Insurance History

Do you currently have insurance on      this property?	yes     no	Company    Exp. Date
Have you ever been canceled, non-      renewed or denied for insurance?      If yes, explain.	yes     no
Have you had any insurance claims      in last five years? If yes give details     including dates and amounts.	yes     no

Comments

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