First Name
Last Name
Street Address
Street 2nd line
City
State
Zip Code
E-mail
Work Phone
Home Phone

Please provide the following information:  

_{Own   Rent}

_{Single Family Home   Two Family Home  Condo   Apartment   Other
                               If Other (describe) :}

_{Please indicate the coverage requested below:
$ Dwelling
$ Other Structures
$ Contents
$ Add'l Living Expense
$ Liability
$ Medical Payments
$ 250 500 1000      Deductible}

_{List any other Additional Coverages here:}

_{Building Information:
Frame Vinyl Siding Alum Siding Masonry Veneer Solid Masonry Construction Type
1 1.5 2 2.5 3 3.5 Number of Stories
Square Feet of 1st Floor Only}
Is there a Basement? No Yes
Home Built in Year
Is there any wood heat?  None Fireplace Only Fireplace w/Insert Wood Stove Other, list in remarks
Is there a swimming pool or trampoline on your premises? No Swimming Pool Trampoline
Is this home a Mobile or Modular Home? No Mobile Home Modular Home
Responding Fire Department
How far in miles is fire dept from your property? miles
Distance to nearest fire hydrant in feet feet

Describe any losses, claims, or accidents in last three years here:

My Current Home Policy is with:

My Policy Expires: 

My Current Insurance Costs      each  Months.

My Social Security Number

If Married, My Spouse's Name  
    & SSN

Any Comments or Additional Notes:

Thank you for taking time to complete this form.  We will forward you information regarding your rates and would be happy to discuss with you personally any questions you may have.  Feel free to phone us at (270) 685-5266.

Thank you again,  Don C. Bradley