Policy Holder
Contact Name*
Date of Birth*
Social Security Number
Email*
Home Phone Number*
Work Phone Number
Best means to contact:
Home Phone
Work Phone
Email
Which local agency would you like to use?*
Please choose one. . . Gosline-Murchie Agency, Gardiner, ME Quirion Insurance Agency, Augusta, ME Pease Insurance Agency, West Rockport Vannah Insurance Agency, Waldoboro, ME Readfield Insurance Agency, Readfield, ME Richmond Insurance Agency, Richmond, ME Kristie Rowell Insurance Services, Hallowell, ME Cornerstone FInancial, Inc., ME RD Johnson Agency, Bethel, ME Erickson Bonding & Insurance Associates, Inc., Augusta, ME
Property Location
Address*
City*
State*
Zip
County*
Current Insurance Information
Company Name
Current Annual Premium
Expiration Date
Deductible Desired
$100 $250 $500 $750 $1,000
Amount of Liability
$300,000 $500,000 $1,000,000
Earthquake Coverage?
Yes
No
Flood Insurance?
Have you filed for bankruptcy in the past 7 years?
About Your Home
Estimated Replacement Value
Square Footage
Year Built
How many floors?
1 Story 1.5 Story 2 Story Bi-Level Tri-Level Other
Type of Construction
Wood Stucco Masonry Vinyl Siding Aluminum Siding Other
Other Features (Check all that apply)
Dead Bolts Smoke Detectors Fire Extinguishers Central Station Fire Alarm Central Station Burgular Alarm Home located within 5 miles of Fire Station Home located within 1000ft of Fire Hydrant Home located within city limits Swimming Pool Trampoline Additional
Claims Please list any claims in the past 3 years.
Date of Claim
Amount Paid
Claim Type
Description
1.
2.
3.
Personal Property Estimated Values.
Jewelry & Watches
Furs
Silver
Firearms
Stamp & Coin Collections
Fine Art & Breakable Items
* indicates required fields
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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