King Insurance Services

Agency Name:

Phone:

Agency Contact:

E-mail Address:

Applicant Name:

Occupation:

Applicant Phone:

DOB:

Location Address:

City:

State: Zip:

New Purchase:

Y N Prior Carrier: Prior Premium:

Lapse in Coverage:

Y N If Yes, Date Of Last Coverage:

If Lapse, Explain:

Occupancy:

If Vacant, Explain:

Number of Families

Distance to Brush

Distance to Fire Hydrant

Protection Class (1 - 10):

Distance to Fire Department

Losses:

Any losses in the Last Five (5) Years? Yes No

If Yes, Explain:

Dwelling Amount:

Extended Replacement Cost:

125% Yes No

Roof Type:

Deductible:

Year Built:

Sq Footage:

Home Updates:

Roof: Plumbing: Electrical: Heating:

Protective Devices:

Burglar Alarm: None Local Central | Smoke Detectors: Yes No

Fire Alarm: None Local Central | Interior Sprinklers: Yes No

Personal Property:

Replacement Cost Y N

Personal Liability:

Water Back Up:

Personal Injury:

Y N Identity Fraud Y N Loss Assessment $5000 $10000

Gated Community:

Yes No

Animals?

Yes No

If yes, what kind:

Wood Burning Stove:

Yes No

Earthquake:

Yes No | EQ Deductible: 10% 15%

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