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PROPERTY  COVERAGES
Personal Property	$         Contents Replacement Cost
Building Property	$
Loss of Use
Loss Assessment	$
Personal Liability	$ 100,000 300,000 500,000
Guest Medical	$ 1,000 2,000 5,000
Back-Up Sewer & Drain	$
Additional Coverage	1) None Jewelry Collectibles Guns Fine Arts           Amount  $
Additional Coverage	2)  None Jewelry Collectibles Guns Fine Arts            Amount  $
Additional Coverage	3)  None Jewelry Collectibles Guns Fine Arts            Amount  $
Child Care on Premises	None 1-3 Children 4-6 Children More than 6 Children
Deductible	$ 250 500 1,000 1,500 2,500 5,000
Current Insurance Company	Choose One AAA AARP AIG Allied Allstate American Express American Family American Modern Home American National American States American West Amica Amoco Apollo Atlanta Casualty Atlantic Mutual Austin Mutual Auto Owners CNA Chubb Cincinnati Mutual Citizen's Commercial Union Dairyland Economy Fire Erie Farm Bureau Farmers Farmers Home Farmers Union Federated Firemans Fund Foremost Geico General Casualty GRE Great American Grinnell Mutual Guaranty National Guide 1 Hanover Hartford Heritage Horace Mann Illinois Farmers IMC Infinity Kemper Liberty Mutual Meridian Met Life Metropolitan Mid-Century Midwest Family Midwest Mutual Milbank Millers Mutual Minnesota Fire MSI Mutual of Omaha Nationwide Ohio Casualty Pafco Pemco Preferred Risk Primerica Progressive Prudential Safeco Secura Sentry Shelter St Paul Cos State Farm State Mutual Teachers Insurance TIG Titan Travelers USAA USF&G Viking Waseca West Bend Western National Westfield Zurich Other None

 

GENERAL INFORMATION
Year Built	Market Value  $
Non- Smoker	Yes   No
Protective Devices	1) Deadbolt locks on doors and at least 1 smoke alarm & fire extinguisher Local fire alarm &/or Smoke alarm Local burglar alarm on doors & windows Burglar and/or Fire alarm connected to central / police station Automatic sprinkler system (partial) Automatic sprinkler system (complete)
Protective Devices	2) None Local fire alarm &/or Smoke alarm Local burglar alarm on doors & windows Deadbolt locks on doors and at least 1 smoke alarm & fire extinguisher Burglar and/or Fire alarm connected to central / police station Automatic sprinkler system (partial) Automatic sprinkler system (complete)
Claims (Last 3 Years)	Date (mo/yr)                 Description
Claim #1
Claim #2
Claim #3

 

CONTACT  INFORMATION
Preferred Method of Contact
E-mail
Phone Number
Fax Number
Postal Mailing Address
Questions or Comments