First Name:
Last Name :
Street Address:
City:
State:
Zip Code:
Phone Number:
Alternate Telephone:
Social Security Number:
Birth of Date:
Email Address:
Referred By:
-Select Referred By-
Bob Arnold, VP
Joe Barrick,VP
Jack Collier
Ben Slingluff,Pres.
Kevin Payne
Steve Thompson,VP
Myron Williams,VP
Elaine Ethridge
Carman Strickland
Judy Lietzan
April Parker
Phyllis Peters
Kandy Groover
Beverly Higginbotham
Ann Johnson
Debbie Kirkland
Sandra Bullard
Sandra Woodham
Sheena Butts
Property Information
Property Street Address
City
State
Zip Code
Number of Bathrooms
Number of Fireplaces
How many porches or decks are there?
What year was it built?
What date was the property purchased?
What is the construction type?
-Select- Brick Stone Frame Masonry Superior Log Cabin Frame-Stucco Masonry Veneer
How many stories is it?
If two stories, what is the ground floor square footage?
Total square footage
What foundation type?
-Select- Crawl Space Piers/Pilings/Stilts Slab on Grade Unfinished Basement Walkout Basement Wood Foundation Basement
If structure is located in a flood zone, what is the distance to body of water? -Select- Do not live in flood zone Less than 100 ft 100-500 ft 500-1000 ft More than 1000 ft
Garage Description
-Select- No Carport-Garage Car Carport Attached Car Carport Detached Garage Attached Garage Detached Tuck Under Parking Above Ground Parking Below Ground Parking Parking Lot Street Parking
What type of roof covering?
Was the roof updated?
If yes, what year?
Does the building have a pool?
If yes, is it fenced?
What is the distance to fire protection?
-Select- 1000 ft or less to hydrant and 5 mi or less to fire station Over 1000 ft to hydrant and 5 MI or less to fire station Over 5 and up to 10 MI to fire station Over 10 MI to fire station
Is the electrical updated?
Are there circuit breakers?
How old is the heating/ air conditioning?
Has the plumbing been updated?
Is there a theft alarm?
What is the fire district?
Are there dogs on the property?
If yes, how many and what is the breed of each dog?
Current Coverage Information
Current Insurance Company
Expiration Date
Were there any losses or claims in the last 5 years?
If yes, what is the date, amount paid and description of each loss or claim?
Desired Coverage Information
Dwelling Amount - Coverage A
Other Structures - Coverage B
Personal Property - Coverage C
Loss of Use - Coverage D
Premise Liability - Coverage E -Select- 100,000 300,000 500,000
Policy Deductible
-Select- 100 250 500 750 1000 2500 5000
Questions or Comments
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