First Name:
(required)
Middle Name:
Last Name:
(required)
Date of Birth:
Social Security #:
Address:
(required)
City:
(required)
State:
IL
IN
WI
(IL, IN, WI only)
Zip Code:
(required)
Telephone:
(required)
Email Address:
(required)
Are you currently insured?
Yes
No
Expiration Date
Name of Current Company
Do you have a renewal notice?
Yes
No
Address of Property
County Name
Within City Limits?
Yes
No
Any Claims in Last 3 Years?
Yes
No
Current Coverage for Dwelling
$
Current Coverage for Liability
$
Year Built
Construction
Brick
Frame
Purchase Price
$
Year Purchased
Mortgage Amount
(if new purchase)
$
Closing Date
0
1
2
3
Kitchen
0
1
2
3
Dinette/Breakfast Nook
0
1
2
3
Living Room
Den or Study/Office
0
1
2
3
Dining Room
Family or Recreation Room
0
1
2
3
4
5
6
7
8
9
10
Bedroom(s) (Larger than 100 sq. ft)
0
1
2
3
4
5
6
7
8
9
10
Bedroom(s) (100 sq. ft or smaller)
0
1
2
3
4
5
6
7
8
9
10
Walk-in Closet/Dressing Room (70 sq. ft or larger)
0
1
2
3
4
5
6
7
8
9
10
Bathrooms (3 or more fixtures)
0
1
2
3
4
5
6
7
8
9
10
Half Bath (2 or less fixtures)
Foyer/Entrance Hall
(omit if part of another room)
Finished Basement (omit if counted elsewhere)
Unfinished Basement
0
1
2
3
Utility or Laundry Room (140 sq. ft or larger)
Finished Attic
(omit if counted elsewhere)
Unfinished Attic
0
1
2
3
Work Room/Storage/Laundry Room (70-140 sq. ft)
Two Car Garage (attached)
One Garage or Carport (attached)
Enclosed Porch/ Breezeway/ Large Open Deck
Brick/Stone Exterior Walls
Brick/Stone Veneer (front wall)
Aluminum/Vinyl Siding
Central A/C (with separate ducts)
Central A/C (using heating ducts)
Fireplace
0
1
2
3
4
5
6
7
8
9
10
Extra Large Rooms (more than 250 sq. ft)
Solar Hot Water Heating Panels
Jacuzzi/Sauna (located in the dwelling)
Clay or Slate Pool
Personal Property Amount
$
Number of Apartments
Construction
Brick
Frame
Number of Roommates
0
1
2
3
4
5
6
Fire Resistive (concrete floors & walls)
Yes
No
Waterbed Liability (damage to apartment below)
Yes
No
Personal Property Amount
$
Number of Units
Construction
Brick
Frame
Number of Roommates
0
1
2
3
4
5
6
Fire Resistive (concrete floors & walls)
Yes
No
Building Additions & Alterations
None
$5,000
$10,000
Loss Assessment Coverage
None
$5,000
$10,000
Personal Liability
$100,000
$300,000
$500,000
Deductible
$250
$500
Smoke Alarm
Yes
No
Burglar Alarm
Yes
No
Central Station
Yes
No
Scheduled Personal
Property Amounts
Jewelery: $
Furs: $
Water Backup Coverage
None
$5,000
$10,000
$25,000
Business on Premises
Yes
No
Type of Business
Describe any losses in last three years
Disclaimer: This does not bind coverage
