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603-433-5600
207-358-7408
978-225-7933
1-888-KANEINS
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603-433-5600
207-358-7408
978-225-7933
1-888-KANEINS
Inland Marine Quote
Home
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 #:
M
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.