Smith & Associates Insurance Agency

Personal Information
* Name:
Street:
City, State:
County:
Township:
Zip Code:
* Email Address:
* Home Phone:
Work Phone:
Occupation:
Employer:
Responding Fire Dept. and Distance:
Curr. Ins. Company:
Annual Premium:
Your SSN:
Spouse SSN:

Coverage Information
Coverage A - Dwelling Amount:
Coverage B - Other Structures:
Coverage C - Personal Property:
Coverage D - Loss of Use:
Coverage E - Personal Liability:
Coverage F - Medical Payments:
Construction:	Brick Frame
Year Built:
Alarm Type:
Square Feet:
# of Full Baths:
# of Half Baths:
Central Air:	Yes No
Woodstove:	Yes No
Fireplace:	Yes No
Foundation:	Basement Crawl Space Slab
Earthquake:	Yes No
Scheduled Jewelry:	Yes No
Collections (Guns, Antiques, etc.):
Number of Acres:
Any farming operation:	Yes No
Dedutible:

Do you operate an in-home business. Please describe.

Any losses in the last six years. Please describe.