Inland Marine
Fields marked (
*
) are mandatory.
Personal Information
Applicant's Name
*
Address
*
City
*
State
*
Please select
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District Of Columbia
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Zip
*
Day Phone
*
Night Phone
Best Time To Call
Email Address
*
Applicant & Location Information
Age
*
Marital Status:
*
Married
Single
Occupation
*
Spouse's Occupation
Territory Code
*
Protect Class
*
Fire District/ Code #
*
Location of Property (if different from above)
Additional Location
Dwelling Type(s)
Construction Type(s)
# Families (in each)
Other
Coverages
Jewelry
Amount ($)
Furs
Amount ($)
Fine Arts
Amount ($)
Cameras
Amount ($)
Musical Instruments
Amount ($)
Silverware
Amount ($)
Stamps
Amount ($)
Coins
Amount ($)
Golfer's Equipment
Amount ($)
Additional Coverage
Amount ($)
Additional Coverage
Amount ($)
Additional Coverage
Amount ($)
Additional Coverage
Amount ($)
Unattended Car Coverage (Stamps/Coins)
Broad Form Pair & Set Coverage
Non-Mobile Organ Coverage
Safe Credit (Identify Property, Safe Class, Etc)
ACV Loss Settlement
Replacement Cost Loss Settlement
Breakage Coverage (*On Schedule)
Blanket Coverage
Additional Rating Information
General Information
Any protective devices/systems in use?
No
Yes
Will any property be exhibited?
No
Yes
Will any special restriction/ endorsements apply?
No
Yes
Will any type of deductible apply?
No
Yes
Is any property used professionally/ commercially?
No
Yes
Any other insurance with this company?
No
Yes
Did any loss occur during the last 3 years?
No
Yes
Any coverage declined, cancelled or non-renewed
during the last 3 years? Not applicable in MO
No
Yes
Prior Insurer & Policy Number
Remarks
Schedule of Property
Provide a detailed description of each item, from whom purchased, etc. Be sure to forward all re quired appraisals/bills.
#
Description
Purchase/ Appraisal Date
Amount of Insurance ($)
#
Description
Purchase/ Appraisal Date
Amount of Insurance ($)
#
Description
Purchase/ Appraisal Date
Amount of Insurance ($)
#
Description
Purchase/ Appraisal Date
Amount of Insurance ($)
#
Description
Purchase/ Appraisal Date
Amount of Insurance ($)
#
Description
Purchase/ Appraisal Date
Amount of Insurance ($)
#
Description
Purchase/ Appraisal Date
Amount of Insurance ($)
#
Description
Purchase/ Appraisal Date
Amount of Insurance ($)
#
Description
Purchase/ Appraisal Date
Amount of Insurance ($)
#
Description
Purchase/ Appraisal Date
Amount of Insurance ($)
#
Description
Purchase/ Appraisal Date
Amount of Insurance ($)
#
Description
Purchase/ Appraisal Date
Amount of Insurance ($)
Additional Comments
Additional Comments