Name:
Address:
City:
State:	Zip:
Email:
Phone:
Fax:
Year Built:
Dweling is contructed of:	FrameFrame/Brick VeneerFrame/vinyl sidingCement Block
Within 3 miles of a Fire Department?:	Yes No
500 feet from Fire Hydrant?:	Yes No
Do you have Smoke Detectors?:	Yes No
Do you have Deadbolt Locks?:	Yes No
Do you have a Fire Extinquisher?:	Yes No
Do you own a Swimming Pool?:	Yes No
Is the Pool Fenced?:	Yes No
Does any Resident Smoke Cigarettes?:	Yes No
Is a Wood Stove present?:	Yes No
Do you operate a Home Business?:	Yes No
Expiration Date of your Current Policy:
What is your age?
What is your Occupation?:
Member of an Association or Group?:
Dwelling:
Other Structures:
Personal Property:
Loss of Use:
Liability:	$100,000$200,000$300,000$400,000$500,000$1,000,000
Medical Payments:	$500$1,000$2,000$3,000$5,000
Deductible:	$100$250$500$1,000$2,500
Replacemenet Cost Contents:	NoYes
Dwelling Replacement Cost:	None125%150%Full
Waive Deductible - Glass:	NoYes
Scheduled Personal Property:	AntiquesCollectablesComputerFine ArtsFur(s)GunsJewelryNoneOther
If Yes:	Give Discription and Value in Comments Section
Recreational Vehicle:	NoneSnowmobileThree WheelerQuad Runner
If Yes:	Give Discription and Value in Comments Section
Boat(s):	NoYes
If Yes:	Give Discription and Value in Comments Section
Do you own rental property?	YesNo
If Yes:	Give Discription and Value in Comments Section
Do you own seasonal property?	NoYes
If Yes:	Give Discription and Value in Comments Section
How would you like us to contact you?	Please choose oneFaxEmailPhoneMail
Comments: