Full Name:*

Date of Birth:

Spouse's Full Name:

Spouse's Date of Birth:

*Street Address:*

City:

State*

ILMO

Zip:*

Email Address:

Day Phone:

Evening Phone:

Contact Preference:

choose one ...EmailDay PhoneEvening Before 6pmEvening Before 8pm

Years at Current Address:

choose one ...1 year2 years3 years4 years5 years or moreNew Purchase

If at current residence less than six months, please provide previous address:

Number of Stories:

choose one ...1 Story1-1/2 Story2 StorySplit LevelBi-LevelOther

Square Footage:

Construction:

choose one ...Frame of StuccoVinyl or Aluminum SidedMasonry (Solid)Masonry VeneerLogMixed ConstructionOther

Attached Garage:

YesNo

Garage - Number of Cars:

choose one ...123

Foundation:

choose one ...SlabCrawl SpaceUnfinished BasementFinished Basement

What percent of basement is finished?

Number of 1/2 bathrooms:

choose one ...12

Number of full bathrooms:

choose one ...123

Type of Roof:

choose one ...ArchitecturalWood ShingleTile or SlateMetalAsphalt Shingle

Age of Roof:

choose one ...1-10 years10-15 years15-20 yearsover 20 years

Please indicate if you have any attached structure:

DeckOpen PorchEnclosed PorchSunroomDeck with Sauna

Please provide square footage of each attached structure:

Do you belong to a homeowner's association?:

YesNo

Is your home in a trust?:

YesNo

Do you own any motorized vehicle not licensed for road use?

YesNo

Do you own a boat or jet ski?

YesNo

Do you run a business in your home?

YesNo

Please give details of any YES item in remarks:

Central Alarm:

choose one ...Burglar alarm onlyFire alarm onlyBurglar and fire alarmNo alarm

Other Protection (check all that apply):

Smoke AlarmsDeadbolt locksFire Extinguishers

Heating:

choose one ...Gas forced airElectric forced airHot waterSolarGeothermalOther

Number of fireplaces:

choose one ...012

Do you have a woodburning stove or furnace in your home?

YesNo

Pets:

DogCatOther

Breed or description:

Year home was built:

Swimming Pool?

choose one ...NoneIn groundAbove ground

Trampoline?

YesNo

Do you have a fenced in backyard?

YesNo

Do you have central air?

YesNo

Electrical-update year:

Heating-update year:

Plumbing-update year:

Have you had any homeowner losses in the past 5 years?

YesNo

If yes, provide dates, amount, and details:

Current policy company:

Renewal or Closing Date:

Deductible:

choose one ...$500$1,000$1,500Other

Is current policy being canceled or non-renewed?

YesNo

If yes, give reason:

Do you have auto insurance through the same company as home?

YesNo

Current Coverage Dwelling:

Current Coverage Contents:

Current Coverage Personal Liability:

choose one ...$300,000$500,000

Current Coverage Medical Payments:

choose one ...$2,000$5,000$10,000$25,000

Optional Coverages - Earthquake:

YesNo

Optional Coverages - Mine Subsidence:

YesNo

Optional Coverage - Sewer Backup:

choose one ...$5,000$10,000$25,000None

Optional Coverage - Scheduled Property:

JewelrySilverGunsHearing AidOther

Personal Umbrella Liability:

choose one ...$1,000,000$2,000,000None

Please provide any additional information:

Please provide any additional information

If you have interest in other forms of insurance, please check all that apply:

AutoHealthDisabilityLong Term CareBoat/Jet SkiFloodInvestment PropertiesRecreational VehiclesLife

Email submit disclaimer*

I understand this form will be transmitted by email to Harnist Insurance for review

Full Name:*

*Street Address:*

City:

State*

ILMO

Zip:*

Email Address:

Day Phone:

Evening Phone:

Contact Preference:

choose one ...EmailDay PhoneEvening Before 6pmEvening Before 8pm

Years at Current Address:

choose one ...1 year2 years3 years4 years5 years or moreNew Purchase

If less than six months, give full previous address:

Do you presently have insurance coverage?

YesNo

If yes, what is the name of the company?

Are you being canceled or non-renewed by your present company?*

YesNo

Vehicle 1 - Year, Make & Model*:

Vehicle 1 - Vehicle Identification Number (VIN):

Vehicle 1 - Usage*:

choose one ...PleasureWork 0-5 milesWork 6-15 milesWork 16-30 milesWork 30+ milesUsed for business

Vehicle 2 - Year, Make & Model:

Vehicle 2 - Vehicle Identification Number (VIN):

Vehicle 2 Usage:

choose one ...PleasureWork 0-5 milesWork 6-15 milesWork 16-30 milesWork 30+ milesUsed for business

Vehicle 3 - Year, Make & Model:

Vehicle 3 - Vehicle Identification Number (VIN):

Vehicle 3 Usage:

choose one ...PleasureWork 0-5 milesWork 6-15 milesWork 16-30 milesWork 30+ milesUsed for business

Vehicle 4 - Year, Make & Model:

Vehicle 4 - Vehicle Identification Number (VIN):

Vehicle 4 Usage:

choose one ...PleasureWork 0-5 milesWork 6-15 milesWork 16-30 milesWork 30+ milesUsed for business

Any Vehicle Custom Add on Equipment - desribe in addl info field below:

YesNo

If yes, please describe and give value:

Driver 1 - Full Name:

Driver 1 - License Number:

Driver 1 - Sex:

MaleFemale

Driver 1 - Date of Birth:

Driver 1 - Years Licensed:

Driver 1 - Full time student:

YesNo

Driver 1 - Away at school:

choose one ...With a car100 to 200 miles without car200+ miles without car

Driver 1 - Good Student B Average?:

YesNo

Driver 1 - Marital Status:

choose one ...MarriedSingleSeparatedDivorcedWidowed

Accidents or Losses last five years:

YesNo

Ticket last five years:

YesNo

Details including dates, tickets, accidents, or other loss:

Driver 2 - Full Name:

Driver 2 - License Number:

Driver 2 - Sex:

MaleFemale

Driver 2 - Date of Birth:

Driver 2 - Years Licensed:

Driver 2 - Full time student:

YesNo

Driver 2 - Away at school:

choose one ...With a car100 to 200 miles without car200+ miles without car

Driver 2 - Good Student B Average?:

YesNo

Driver 2 - Marital Status:

choose one ...MarriedSingleSeparatedDivorcedWidowed

Accidents or Losses last five years:

YesNo

Ticket last five years:

YesNo

Details including dates, tickets, accidents, or other loss:

Driver 3 - Full Name:

Driver 3 - License Number:

Driver 3 - Sex:

MaleFemale

Driver 3 - Date of Birth:

Driver 3 - Years Licensed:

Driver 3 - Full time student:

YesNo

Driver 3 - Away at school:

choose one ...With a car100 to 200 miles without car200+ miles without car

Driver 3 - Good Student B Average?:

YesNo

Driver 3 - Marital Status:

choose one ...MarriedSingleSeparatedDivorcedWidowed

Accidents or Losses last five years:

YesNo

Ticket last five years:

YesNo

Details including dates, tickets, accidents, or other loss:

Driver 4 - Full Name:

Driver 4 - License Number:

Driver 4 - Sex:

MaleFemale

Driver 4 - Date of Birth:

Driver 4 - Years Licensed:

Driver 4 - Full time student:

YesNo

Driver 4 - Away at school:

choose one ...With a car100 to 200 miles without car200+ miles without car

Driver 4 - Good Student B Average?:

YesNo

Driver 4 - Marital Status:

choose one ...MarriedSingleSeparatedDivorcedWidowed

Accidents or Losses last five years:

YesNo

Ticket last five years:

YesNo

Details including dates, tickets, accidents, or other loss:

Bodily injury limit - all vehicles (,000's)*:

choose one ...50/100100/300250/500500/1,000100 single limit300 single limit500 single limit

Property damage limit - all vehicles (,000's)*:

choose one ...50100300500Incl.

Medical payment limit - all vehicles (,000's)*:

choose one ...251025None

Uninsured/Underinsured Motorist - all vehicles (,000's)*:

choose one ...50/100100/300250/500500/1,000100 single limit200 single limit300 single limit

Comprehensive deductible:

choose one ...$50$100$250$500No coverage

Which vehicle - check all that apply:

All vehiclesVehicle 1Vehicle 2Vehicle 3Vehicle 4

Collision deductible:

choose one ...$100$250$500$1,000

Which vehicle - check all that apply:

All vehiclesVehicle 1Vehicle 2Vehicle 3Vehicle 4

Towing - check all that apply:

All vehiclesVehicle 1Vehicle 2Vehicle 3Vehicle 4

Car Rental:

YesNo

Please provide any additional information here:

If you have interest in other forms of insurance, please check all that apply:

HomeLifeHealthDisabilityLong Term CareBoat/Jet SkiFloodInvestment propertyRecreational vehicles

Email submit disclaimer*

I understand this form will be transmitted by email to Harnist Insurance for review