General Information

If you have more than two residences, please fill out an additional form and leave a short note to that effect in the comment section at the end of this form.

First Name: Last Name: MI
Address (street):
Address (cont ):
City:
County:State: Zip:
Phone Number:
Fax Number:

Social Security #  (required for Accurate Quote):
    The Cain Agency Guarantees the usage of Social Security # is for Quote Purposes only.
E-Mail Address:
Your present insurer:
Your policy expiration date:
Have you had insurance coverage for the last 12 months?: Yes No

Type of policy to quote:Homeowners RentersCondo OwnersTownhome
Building Size:1 Story2 StoryBi-Level
Approx. Square Foot (Homeowners Only):
Year Built:
If Renter's or Condo Policy, How many units in building?:
Building Type:BrickFrameAlum.SidingFire Resistant

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Responding Fire Department's name:
Is your fire department a volunteer fire department?: Yes No
Do you live within the city limits?: Yes No
Do you have smoke detectors?: Yes No
Heating Type: GasOilElectricWood Stove

Claims History

List any claims you have had within the last five years. If you have had any claims in the past f ive years, please list date and amount of claim(s).

 

Coverages

The dwelling coverage on your present policy or purchase price if quote is for a new purchase home:
If requesting a quote on Renters or Condo, enter your present policies coverage on contents.

If Quote is for new purchase, estimate what all belongings are worth. (Furniture, appliances, jewelry, stereo, TV's etc.): $
Liability Coverage Requested:$300,000$500,000
Medical Payments:$1,000$5,000
Deductible Requested:$250$500$1,000

Replacement Cost

Do you have guaranteed replacement cost on dwelling?:YesNo
Do you have guaranteed replacement cost on contents?:YesNo

Cain Agency will forward the necessary census to you by your choice of response method.
Please choose one of the following:
EMAIL     POSTAL MAIL    FAX    PHONE  

COMMENTS : Enter any comments, clarifications, explanations, and/or questions here: