| *
Required |
This quote is for an
estimate only and does not give any coverage. Actual policy
coverage and premiums my differ or not be provided after
underwriting review. |
|
Currently
Insured By: |
Company
Name |
|
Current
Policy Expires: |
Month/Year |
| * |
First Name |
|
| |
Middle
Initial |
|
| * |
Last Name |
|
| |
Business
Name |
|
| |
Business
Type |
|
| |
Street
Address |
|
| |
City |
|
| |
State |
|
| |
Zip |
|
| |
Home Phone |
|
| |
Cell Phone |
|
| |
Business
Phone |
|
| * |
Email
Address |
|
|
I
prefer to be contacted by: |
|
| * |
I grant Interlakes Insurance permission
to secure your credit and/or claim history, for insurance
purposes only, under the Fair Credit Reporting Act. |
|
Home
/ Condo Information: |
|
Dwelling
Amount |
|
Personal
property (contents), outbuilding coverage, and additional
living expenses are calculated from the dwelling amount;
list below your current coverage |
|
|
|
Property
Coverage Deductible |
|
|
Comprehensive
Liability Amount |
|
|
Medical
Payment |
|
|
Replacement
Costs |
|
|
Water
Damage |
|
|
Construction
Type |
|
|
Dwelling
Type |
|
|
Building's
Stories |
|
|
For
Condo/Apartment - Personal Property |
Dollar
Amount |
|
Year
Built |
|
|
Nearest
Fire Hydrant |
|
|
Fire
Station |
|
|
Location
to City Limits |
|
|
Roof
Type |
|
|
Alarm
Systems |
|
|
Sprinkler
Systems |
|
|
Is
there a Business on the Premises? |
|
|
If
Yes, Type of Business |
|
|
Animals
on Premises? |
|
|
If
Yes, Type / Quantity / Weight |
|
|
Any
Losses within the Past 3 Years? |
|
|
If
Yes, Pls Describe / Explain |
|
|
Additional
Comments |
|
| |
This quote
is for an estimate only and does not give any coverage. Actual
policy coverage and premiums my differ or not be provided
after underwriting review. |
