APPLICANT INFORMATION

Name:    Spouse's Name:

Date of Birth   Spouse's Date of Birth

Mailing Address:  City: State: Zip:

Home Phone:     Work Phone:

DWELLING INFORMATION

Home Address:  City: State: Zip:

Primary Home    Seasonal Home

Fire Department   Miles to FD   Hydrant w/in 1000 ft? Yes No

Is your home currently insured?  Yes No

If 'No', is it a new purchase? Yes No    Closing Date: 

If 'Yes', Company Name   Expiration Date

Are you being canceled or non-renewed?  Yes No 

If 'Yes', reason

VALUES INSURED FOR

Dwelling $

Other Structures/Outbuildings $

Personal Property $

Loss of Use $

Personal Liability:  $100,000 $300,000 $500,000 $1,000,000      Medical Payments: $1,000 $5,000 $10,000

Deductible: $250 $500 $1,000 $2,500

GENERAL INFORMATION

Year Home Built    Frame  Modular  Mobile Home  Log

Foundation:  Basement  Crawlspace  Slab  Continuous Block  Skirting w/ Pillars

Electrical:  Fuses   Breakers    Amp Service:       Year Updated

Roof Type:  Shingles   Steel   Cedar Shakes   Other   Year Updated

Number of Stories     Number of Baths     Hot Tub? yes no

Basement? yes no      Finished?  yes no      Walkout?  yes no

All Heat Sources:  LP Gas   Natural Gas   Electric   Outdoor Woodstove

                            Fireplace   Indoor Woodstove   None   Other

Protective Devices:   smoke detectors   fire ext.   deadbolts   alarm system

Central Air? yes no     

Garage?  yes no    Attached?  yes no    # of Cars:

Number of claims in the past 5 years:

Number of Acres:    Rent any acres? yes no    Rental Usage: None Crop Pasture

Trampoline? yes no      Fenced yard?  yes no     Protective net? yes no

Swimming Pool? yes no    Fenced in? yes no    Locked gates? yes no

Bankruptcy in past 5 years? yes no

Run a business out of home? yes no    If yes, what type?

Do you have auto insurance? yes no    If yes, with what company?

Additional endorsements or coverage provided on current policy:

How would you like us to contact you?