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Personal Inland Marine Quote Form

 

Personal Inland Marine Insurance Quote
We would like to provide you with a free, no-obligation insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

 

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
Any protective devices/systems in use? Y N
Will any property be exhibited? Y N
Will any special restriction/ endorsements apply? Y N
Will any type of deductible apply? Y N
Is any property used professionally/ commercially? Y N
Any other insurance with this company? Y N
Did any loss occur during the last 3 years? Y N
Any coverage declined, cancelled or non-renewed during the last 3 years?
(Not applicable in MO)		 Y N
Prior Insuror & Policy Number(s)
Remarks:

 

Schedule of Property
#
Provide a detailed description of each item, where
purchased, etc. Also forward all required appraisals/bills.
Purchase/
Appraisal Date
Amount of
Insurance
1.
$
2.
$
3.
$
4.
$
5.
$
6.
$
7.
$
8.
$
9.
$
10.
$
11.
$
12.
$
13.
$
14.
$
15.
$
Please use "Additional Comments" below 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, such as additional coverages, schedule of property, etc..., please enter them here.


Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

   

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