HOMEOWNER/DWELLING QUOTE FORM

Please fill out all (*) required information.  Spouse or Co-owner may be filled in with a (0) zero ONLY if it is NOT applicable to you.  Any incorrect or incomplete information may result in an inaccurate quote.  Please feel free to call our agents at (620) 221-1760 with any questions or quotes with special needs.

Insured Name*
Phone Number*

Email Address*
Insured Social Security Number*
Insured Date of Birth*

Spouse or Co-Owner Name*
Spouse or Co-Owner Social Security Number*
Spouse or Co-Owner Date of Birth*

Insured Property Address*
City, State, Zip*
Number of Acres
Outbuildings (Age and Size)
Purchase Price*
Closing Date if New Purchase*

Construction Material
Year Built
Number of Stories
Ground Floor Square Feet
Total Living Area
Age and Type of Roof*
                 
Bathrooms


Fireplace or Woodstove*
Yes
No
Type of Heat
Type of Air
Garage

Current Insurance Company*
Current Policy Number
Expiration Date of Current Policy
Describe any losses and the amount paid in the last three years*
Breed of any dogs on the premises*
Trampoline on the premises*
Yes
No
Describe any items to be scheduled and/or Recreational Vehicles

CREDIT & LOSS HISTORY REPORTS MAY BE ORDERED BY THE AGENCY FOR QUALIFICATION PURPOSES

QUOTES ARE SUBJECT TO COMPANY APPROVAL

OUR AGENTS ARE LICENSED TO SELL IN KANSAS ONLY