Bill Higley Insurance for Auto, Home, Life Insurance

Bill Higley Insurance - Skip Molen, Agent

Insurance - Auto, Home, Commercial, Life, Bonds, Medical

Name:

Insured's Home Phone:

Address:

Insured's Work Phone:

Address:

County:

Email:

Property Location:

Same as Above

Have you had any losses (property or casualty) during the last 3 years? Yes No

Have you had property/casualty insurance cancelled, refused, or declined in the last 3 years? Yes No

Is there a trampoline? Yes No Note: If Yes, you do not qualify for insurance.

Does the applicant own a dog or exotic pet? Yes No If Yes, what breed?

If mobile/manufactured home, does the risk meet snow load requirements of the county? Yes No

How long at present address?

Information on Primary Dwelling

Square Feet:

First Floor:
Second Floor:
Basement:
Attached Garage:

Est. Replace Cost: $
Name Fire Dist:
Ft. to Fire Hydrant:
Miles to Fire Station:
Construction:
Date Remodeled:
Type of Heat:
Type Roof:
Date Plumbed:
When Wired:
Circuit Breakers: Yes No
Wood Stove: Yes No

PRESENT COVERAGE	PRESENT AMOUNT
A. Dwelling:
Owner Occupied Rental Vacant Seasonal
If Manufactured Home: Make SN Anchored: Yes No
B. Homeowners - Other Stuctures: Farmowners - Private Garage:
C. Personal Property:
D. Loss of Use:
Wood Stove /Fireplace Insert / Multi-level Surcharge:
Any Supplemental Heat? Yes No If Yes, Type:
Dead Bolts Burglar Alarm Smoke Detectors Fire Extinguisher

LIABILITY SECTION:

Liability Limits: $100,000 $300,000 $500,000 $1,000,000

Medical payments to others only available on owner occupied dwellings - not seasonals: $1,000 $2,000 $5,000

Any business conducted on premises including day/child care? Yes No

Note: For a copy, print this form.