* Agency #:    E-mail Address:

* Agency Name:

General Information

* Applicant Name:    Date of Birth:

Purchased (mm/yyyy):    * # of Family:    * # of Stories:    * Construction:Select OneFrameMasonry

Prior Coverage on this Property:Select OneYesNo    Expiration of Prior Coverage (mm/yyyy):

Square Footage:    * County:    * Protection Class:Select One12345678910    City Limits:Select OneYesNo  

Occupancy:Select OnePrimarySeasonalRental    Year Built:

Additional Rating Factors

Credits

Protection Devices:Select OneNoneSmoke Alarm-Dead Bolts-Fire ExtinguisherCentral Station Alarm-monitored 24 hours

Number of claims filed on this property within the last 12 months:

Number of claims filed on this property within the last 24 months:

Surcharges

Filed Bankruptcy in last 3 years:Select OneYesNo

Supplemental Heating System:Select OneNoneWood Stove

How many non-weather related claims over the past 3 years:

Property (Primary or Seasonal)

Dwelling Value:    Other Structures:    Deductible:5002501,0002,500

Personal Property:    Personal Liability (Owner & Seasonal):Select OneNone25,00050,000100,000300,000    Med Pay:Select OneNone5001,000

Burglary (available for primary owner occupied residence only):Select One2,0004,0005,000

Additional Living Expense:Select oneYesNo     VM&M (not available on Seasonal property):Select OneYesNo

Rental Property

Dwelling Value:    Other Structures:   Deductible:5002501,0002,500

Premises Liability (Rental Only):Select OneNone25,00050,000100,000300,000    Med Pay:Select OneNone5001,000

Fair Rental Value:Select OneYesNo    VM&M:Select OneYesNo

Comments: