Inter-Agency Insurance Service, Inc.

Your home is probably your most valuable asset. For this reason, you should have a homeowner policy that gives you the protection you need at the best possible price. Fill out the preliminary form below and one of our agents will contact you.

Named Insured #1

Social Security Number

Date of Birth

Named Insured #2

Social Security Number

Date of Birth

Address

City

State

Zip

Phone

Married Yes No

E-mail

How Long Employed?

Occupation

Children

Yes No

If yes, Names and Ages

How long at current address?

Current Insurance Company

Any claims / losses in the last three years?

Information

Insurance Value of the House

Listed Items to schedule and value

Deductable

$250 $500 $1,000 $2,500 $5,000

Limit of Liability

$100,000 $300,000 $500,000 $1,000,000

Age of House

Construction of House

Frame Brick Stucco Vinyl

Style of House

1 Story 2 Story 3 Story Split Foyer Bi-Level

Basement

Yes No

Finished Yes No

Basement Square Footage

Garage

Yes No

Attached Yes No

Number of Cars

Inside City Limits

Yes No

Responding Fire Dept.

Total Square Footage

Main Level Square Footage

# of Bedrooms

# of full Bathrooms

# of half Bathrooms

Living Room
Yes No

Kitchen
Yes No

Den/Family Room
Yes No

Dining Room
Yes No

Laundry Room
Yes No

Foyer
Yes No

Other Rooms (describe)

Central Heat & Air Yes No

# of Ceiling Fans

Alarm System Yes No

If yes, is it a Central Station Alarm? Yes No

Smoke Alarms
Yes No

Dead Bolt Locks
Yes No

Smokers
Yes No

# of Fireplaces

# of Chimneys

Is fireplace pre-fab
Yes No

Any Decks/Porches
Yes No

If yes, Estimate size:

Do you have a swimming pool?
Yes No

If yes, is pool fenced?
Yes No

Located in Subdivision: