Inland Marine Quote

  • Personal Information
    Applicant's Name:
    Address:
    City:   State:   Zip:
    Day Phone:   Night Phone:
    Best Time To Call:   AM   PM
    Email Address:
  • Applicant & Location Information
     
    Age:
    Marital
    Status:
     
    Occupation:
    Spouse's
    Occupation:
    Territory
    Code:
    Protect
    Class:
    Fire District/
    Code #:
    S
    Location of Property
    (if different from above):
    Dwelling
    Type(s):
    Construction
    Type(s):
    # Families
    (in each):

    Additional Location
    Other: 
  • Coverages
    Please indicate additional property that is not listed in boxes 10-14
    #
    Property
    Amount of Ins.

    #
    Property
    Amount of Ins.
      1 Jewelry $ 8 Coins $
    2 Furs $ 9 Golfer's Equipment $
    3 Fine Arts $ 10 $
    4 Cameras $ 11 $
    5 Musical Instruments $ 12 $
    6 Silverware $ 13 $
    7 Stamps $ 14 $
    Unattended Car Coverage (Stamps/Coins)
    Broad Form Pair & Set Coverage
    Non-Mobile Organ Coverage
    Safe Credit (Identify Property, Safe Class, Etc)
      ACV Loss Settlement
    Replacement Cost Loss Settlement
    Breakage Coverage (*On Schedule)
    Blanket Coverage
    Additional Rating Information
  • General Information
    Explain All "Yes" Responses in Remarks
    Yes/No

    Explain All "Yes" Responses in Remarks
    Yes/No
    1. Any protective devices/systems in use? Y
    N
    6. Any other insurance with this company? Y
    N
    2. Will any property be exhibited? Y
    N
    7. Did any loss occur during the last 3 years? Y
    N
    3. Will any special restriction/ endorsements apply? Y
    N
    8. Any coverage declined, cancelled or non-renewed during the last 3 years? Not applicable in MO Y
    N
    4. Will any type of deductible apply? Y
    N
    Prior Insuror & Policy Number
    5. Is any property used professionally/ commercially? Y
    N
    Remarks
  • Schedule of Property
    #
    Provide a detailed description of each item, from whom purchased, etc. Be sure to forward all required appraisals/bills. Purchase/
    Appraisal Date
    Amount of Insurance
    $
    $
    $
    $
    $
    $
    $
    $
    $
    $
    $
    $
    $
    $
    Please use "Additional Comments" section at the bottom of this form for any additional entries.
  • Additional Comments
    Please give any additional comments you feel appropriate for this quotation. If you have
    additional information where there was not enough fields above, please enter them here.