Inland Marine Insurance Quote
 

Personal Information

Please fill in all of the requested information and an agent will contact you immediately with your quote as well as answer any of your insurance related questions.

Employer Name: (Required)
Name: (Required)
Address: (Required)
City: (Required)
 		State: (Required)
 		Zip Code: (Required)
E-Mail Address:
Phone Number:
 Fax Number:
Occupation:
 Length of Time at Current Job?
Social Security Number:
(Not Required, but some of our insurance companies can't quote without it)

Dwelling Information
Name of Current Carrier:
Date Current Policy Expires:
 Amount of Current Insurance?
How Long at Current Address?
 Number of Families Living in Dwelling
Deductible
 Liability
Is This your Primary Residence?
Yes No		 Any Claims in Past 3 Years:
Yes No

If Yes (To claims in the past 3 years), Please Enter Date of Loss, Amount of Loss and Cause of Loss:

Home Construction Information
Square Footage, Heated and Cooled:
 Year Home was Built:
Number of Stories:

 		Construction of Home:

Foundation:
Smoke Detectors?
Yes No		 Burglar/Fire Alarm?
Yes No		 Is Alarm Monitored?
Yes No

Coverages
Property Amount of Ins Rate Premium
Jewelry
Furs
Fine Arts
Cameras
Musical Instruments
Silverware
Stamps
Coins
Golf Equipment
Personal Computers

General Information
Protective Devices/Systems in use?  Yes  No
Will any property be exhibited?  Yes  No
Will any special restriction/endorsements apply?  Yes  No
Will any type of deductible apply?  Yes  No
Is any property used professionally/commercially?  Yes  No
Any other Insurance with this company?  Yes  No
Has any loss occurred during the last 3 years?  Yes  No
Any coverage declined, cancelled or non-renewed during the last 3 years?
Yes  No
Any Comments You Feel May be Helpful to us in Providing You with This Proposal:
How May We Contact You?
Email Fax Telephone		 Best Time to Call?
AM PM

Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way.  If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me.

 

All information submitted will be kept in strict confidence