Brad Lignell Insurance Agency
Email Us





























Site by 
 DragonSoft Data Systems, Inc
    Home    Quote    Services    Links    ContactUs   
Today's Date
Effective Date:
Full Name Spouse's Name
Birthdate: Birthdate
SSN# SSN#
 Insured Street County
City
State Zip
Daytime Phone:   Evening Phone:
E-Mail Address

Year Built: Roof Type: Roof Age:
Living Square Feet # of Floors: # of Full Baths
# of 1/2 Baths Exterior Wall: Usage:
Garage: Garage: # of Fireplaces:
Date of Purchase: Purchase Price
Current Insurance Carrier: Expiration Date:
If New Purchase, Estimated Closing Date

Loss History: List any and all losses for both the applicant and the residence to be insured for previous 3 years.
  Date: Type: Location: Amount Paid
1.
2.
3.
4.

General Information:
1. Is house located within city Limits:
2. Does risk have central heating?
 

If no, what type
3. Is there a swimming pool?
  Is there a slide or diving board?
  Is the pool completely fenced in?
4. Are there any pets?
 

What Type?
5. Are the following in good condition:?  
 

Wiring?
 

Plumbing?
 

Heating?
 

Roof?
 

If NO to any, Explain:
6. Year of any renovation or replacement of:  
 

Wiring
 

Plumbing
 

Heating
7. Is the risk vacant, for sale, in the course of new construction or renovation?
8. Is there any business (including child care) conducted on the premises?
  If yes, explain:
9. Does the residence have a monitored Alarm system?
  Please list any other information about the residence in this section::
© 2001-2002 Brad Lignell Insurance Agency. All Rights Reserved.