Insured Information

First Name:

Last Name:

Email:

Address:

City:

State: AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VI VA WA WV WI WY

Zip:

County

How many years in current residence? less than 1 1 2 3 4 5 6 7 8 9 10 more than 10

Work phone number, including area code: ext:

Home phone number including area code:

Fax phone number including area code:

Are you currently insured? Yes No

If yes, who are you insured with?

Have you been cancelled or non-renewed? Yes No

How did you hear about us? KSCS 96.3 The Edge KZPS KESS KISS FM The Ranch 95.9 FM The Wolf 99.5 FM The Twister 96.7 FM KLTY 94.9 FM The Bone 93.3 FM Mix 102.9 FM Yellow Pages TV Billboard Friend told me Relative told me Another Agent Referred Me Google Yahoo Other On-Line Search

Resident's Information

Date of birth:

Marital Status Married Single Widowed Divorced

Sex: Male Female

Social Security #:

Occupation:

Employer:

Years with current employer:

Mobile Home Information

Is this a mobile home? Yes No

Structure Information

Construction: Brick/Veneer Frame Asbestos/Stucco Vinyl Other

Roof: Metal Composition Wood Shingle

Foundation: Slab Pier and Beam

Year built:

Square Feet:

Central Heating/Air Conditioning Yes No

This dwelling has a: Garage Carport Neither

How many vehicles can the above hold?

Is the Garage/Carport attached or detached? Attached Detached

Home is occupied by: Owner Tenant

Age of roof (years):

Number of rooms (not including garage):

Number of full bathrooms:

Number of half bathrooms:

Trampoline: Yes No

Hot tub: Yes No

Pool: Yes No

Is dwelling more than 20 years old? Yes No

Seasonal dwelling: Yes No

In city limits: Yes No

Business activity in home: Yes No

Distance to fire hydrant (feet) 0 - 500 501 - 1000 more than 1000

How far to fire department?

Name/city of fire department:

Fireplace: Yes No

Fire/burglar alarm: Yes No

Is the dwelling occupied during the day? Yes No

Animals: Yes No

Bankruptcy in the last 5 years: Yes No

Your credit for the last 5 years has been: Excellent Good Acceptable Poor

Repossessions in the last 5 years: Yes No

Unpaid Tax Liens in the past 5 years: Yes No

Unpaid Judgments in the last 5 years: Yes No

Coverage Information

Dwelling value amount:

Personal Property Amount:

Liability limit:

Extra Information

Would you like to fill out an auto quote next to see if you qualify for additional discounts? Yes No

Prior insurance: Yes No