Name:

Address:

City, state and zip:

County:

Date of Birth:

Email:

Daytime phone:

FAX:

Do you currently attend a Mennonite, Brethren in Christ or Missionary Church? Yes No

Current Insurance Company (not agency):

Company name:

Policy exp. date (month/year):

Policy Term:

Current premium:

Current deductible:

Home Information

How long at present address:

Year home was built:

Is business conducted on the premises?

Sq. footage of home (excluding garage and basement):

Number of claims in last 3 years:

Number of families dwelling is designed for:

Who lives in the dwelling?

What part of the year is the dwelling occupied?

Distance to fire hydrant:

Distance to fire station:

Liability coverage limit:

Deductible:

Structure Information

Type:

Construction:

Roof:

Foundation:

Garage:

Features

Bathrooms:

Basement:

Deck sq. ft:

Porch sq. ft:

Screened patio sq. ft:

Fireplaces:

Number of hearths:

Additional Features

Heating system:

Central air:

Central vacuum:

Security alarm:

Fire alarm:

Smoke detector:

Additional Comments: