Personal Information
Name:
Address: City: State: KS Zip Code:
Phone: EMAIL:
Social Sec No.: Date of Birth:
Home Information
Rental House Address: City:
Year Built: Number of Families:
Construction Type:
Coverage type: Replacement coverage: (you must insure the house for replacement value) or
Actual Cash value (cost of repair minus depreciation)
Within City Limits? YesNo Non-Smokers:
Installed Protection Devices: (Check all that apply)
Smoke AlarmsFire ExtinguishersDead Bolts
Burglar Alarm MonitoredBurglar Alarm w/ Siren
Coverage
Home Value: Deductible:
Liability:
Are you interested in any of our other Products? (check all that apply)
Auto InsuranceLife InsuranceMedical InsuranceAnnuities
Boatowners Cycle Ins Business
Any Message? Questions? Special Considerations?
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