EJ Insurance Wichita Kansas Insurance Life Home Auto

HomeOwners Insurance

CONTACT INFORMATION

		Yourself		Your Spouse
Name
Telephone Number
Alternate Telephone
Email Address
Occupation
Social Security Number
Date of Birth
Housing	Mailing Address		Property Address

PROPERTY DETAILS

Year Built		# of Bedrooms
Main Floor Square Footage		# of Bathrooms
Style		Basement?
Garage		Walk-Out Basement?
Roof Type		Percent Basement Finished
Inside City Limits?		Within 500 feet of fire hydrant?

PLEASE PROVIDE PERCENTAGES FOR THE FOLLOWING (all must total 100% for each category):

CONSTRUCTION:	Frame	Brick	Alum/Vinyl
FLOORING:	Carpet	Hardwood	Vinyl/Tile
WALLCOVERING:	Paint	Walpaper	Panel

PLEASE PROVIDE THE NUMBER OF EACH OF THE FOLLOWING:

Fireplaces	Garage Door Openers	Skylights
Smoke Detectors	Exterior Shutters (pr)	Porches
Fire Extinguishers	Deadbolts	Pets

PLEASE SELECT EACH OF THE FOLLOWING THAT ARE IN THE HOME:

Circuit Breaker?		Amp Capacity?		Heat Source
Plumbing Type		Any Electrical, plumbing, or heating/air renovations in the past 10 years?

INSURANCE COVERAGES:

Losses/Claims in the Past 3 Years?

Premiums Escrowed?

If there have been claims in the past 3 years, please describe:

MORTGAGE INFORMATION:

Mortgage Company

Loan Number

Deliver my rates via

I certify that the information contained in this form is true and correct to the best of my knowledge. I understand that I am submitting this information to EJ Insurance Agency, an authorized Farmers Insurance Agent. I further understand and permit EJ Insurance Agency, to obtain any credit and/or driving records as required for providing an accurate rate.

My initials here indicate my understanding and agreement with these statements.

CONTACT INFORMATION

Yourself

Your Spouse

Name

Housing