Account Representative / Referral Please select your account representative, or leave as "General Representative" if you do not have one: General Representative Carol McIsaac Donna Foster Judith Graham Kathy East Margaret Rosa Teresa Heupel Toni Peconi Valerie King Referred By / To:

 

Personal Information Applicant's Name: Address: City:   State:   Zip: Day Phone:   Night Phone: Best Time To Call:   AM   PM Email Address:

 

Applicant & Location Information   Age: Marital Status:   Occupation: Spouse's Occupation: Territory Code: Protect Class: Fire District/ Code #: M S Location of Property (if different from above): Dwelling Type(s): Construction Type(s): # Families (in each): Additional Location Other:

 

Coverages Please indicate additional property that is not listed in boxes 10-14 # Property Amount of Ins. # Property Amount of Ins.   1 Jewelry $ 8 Coins $ 2 Furs $ 9 Golfer's Equipment $ 3 Fine Arts $ 10 $ 4 Cameras $ 11 $ 5 Musical Instruments $ 12 $ 6 Silverware $ 13 $ 7 Stamps $ 14 $ Unattended Car Coverage (Stamps/Coins) Broad Form Pair & Set Coverage Non-Mobile Organ Coverage Safe Credit (Identify Property, Safe Class, Etc)   ACV Loss Settlement Replacement Cost Loss Settlement Breakage Coverage (*On Schedule) Blanket Coverage Additional Rating Information

 

General Information Explain All "Yes" Responses in Remarks Yes/No Explain All "Yes" Responses in Remarks Yes/No 1. Any protective devices/systems in use? Y N 6. Any other insurance with this company? Y N 2. Will any property be exhibited? Y N 7. Did any loss occur during the last 3 years? Y N 3. Will any special restriction/ endorsements apply? Y N 8. Any coverage declined, cancelled or non-renewed during the last 3 years? Not applicable in MO Y N 4. Will any type of deductible apply? Y N Prior Insuror & Policy Number 5. Is any property used professionally/ commercially? Y N Remarks

 

Schedule of Property # Provide a detailed description of each item, from whom purchased, etc. Be sure to forward all required appraisals/bills. Purchase/ Appraisal Date Amount of Insurance $ $ $ $ $ $ $ $ $ $ $ $ $ $ Please use the "Additional Comments" section at the bottom of this form for additional entries.

 

Additional Comments Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, such as additional coverages, schedule of property, etc..., please enter them here.

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