Inland Marine

Fields marked (*) are mandatory.

Personal Information

Applicant's Name*
Address*
City*
State*
Zip*
Day Phone*
Night Phone
Best Time To Call
Email Address*

Applicant & Location Information

Age*
Marital Status:*
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?
Will any property be exhibited?
Will any special restriction/ endorsements apply?
Will any type of deductible apply?
Is any property used professionally/ commercially?
Any other insurance with this company?
Did any loss occur during the last 3 years?
Any coverage declined, cancelled or non-renewed
during the last 3 years? Not applicable in MO
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