1st State Agency of
Sauk Centre, Minnesota, will contact you by phone within 3 business days.
| *Last |
|
| *First |
|
| *Middle |
|
| *Address |
|
| *City |
|
| *State |
|
| *Zip |
|
| *Home
Phone |
|
| Work
Phone |
|
| Fax |
|
| Email |
|
Date
of Birth |
|
| Credit |
|
Occupation |
|
Years
@ present job |
Structure Information
| Miles from FD | ||
| Any acerage | ||
| Type of heat: | ||
| In floor radiant heating? | |
If yes, % |
| Woodstove |
Yes No |
|
| Type of flue | ||
| Fireplace | ||
| Chimney |
Yes No |
|
| Year Built | ||
| Wiring Updated? |
year |
|
| Plumbing Updated? | year | |
| Roof Updated? |
year |
|
| Heating Updated? | year | |
| Home Dimensions (without garage) | |
|
| What type of garage? | ||
| Detached Structures (dimensions) | ||
| Deck (sq feet) | ||
| Type of Siding | ||
| Central Air |
Yes No |
|
| Hot Tub |
Yes No |
|
| # Of Bathrooms | ||
| Cathedral Ceilings | If yes, % |
|
| Recessed Lighting | If yes, % | |
| Wall Covering | ||
| Ceilings | ||
| Windows | ||
| Doors | ||
| Flooring |
% Oak % Laminate % Carpet % Tile % Vinyl % Other |
|
| Basement | ||
Home Style
| Rambler | Yes |
| Bi-Level |
Yes |
| Tri-Level | Yes |
| Basement |
|
| Basement Finished |
Yes No |
| Basement Finished | If yes, % |
| Balcony (sq feet) | |
| Breezeway (sq feet) | |
| Patio |
Previous Coverage
| Current Insurance Provider | |
| Policy # | |
| Expiration Date | |
| Current Deductible | |
| Dwelling Value | |
| Other Structures |
|
| Personal Property | |
| Liability | |
| Medical Pay | |
| Loss of Use | |
| Replacement Cost On Personal Property |
Yes No |
| Guaranteed Replacement Cost on Home |
Yes No |
Mortagee
Remarks/Comments
| Many insurance agencies use information gathered from you and outside sources about your claim, driving or credit history. This information helps insurance companies determine the proper quote. Comanies that
claim to get you a quote in 15 minutes or less, are placing speed
over accuracy and personal attention is no longer part of the equation.
First State Agency will not push you towards something you don't
want or need, we will guide you. |