| *Name: |
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| *Email address or phone number: |
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| *Are you a member of Indiana Members Credit Union? |
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| *Address: |
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| Address of home to insure if different: | |
| *Year home was built: |
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| *How many stories is your home: |
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| *Exterior of home: |
Brick
Frame
Vinyl
Other |
| *Square footage: |
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| *Number of bedrooms |
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| *Full or half bathroom: |
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| *Please check the following that apply: |
Living Room
Dining Room
Front Room
Basement
Slab
Crawl Space
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| *Do you have a 1, 2, 3, or 4 car garage: |
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| *Is your garage attached or detached: |
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| *Is the garage Brick, Frame, Vinyl or Block: |
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| *Select the following if they apply to your home: |
Fireplace
Woodstove
Swimming Pool
Trampoline |
| If your home is over 15 years old, please indicate updates: |
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Electrical type:
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Fuse
Circuit Breaker
Year it was updated:
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| Furnace: |
Gas
Electric
Other
Year it was updated:
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| Roof: |
Shingle
Slate
Metal
Other
Year it was updated:
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| *Replacement value of (or amount to rebuild) your home: | |
| *Deductible amount for quote: |
$250
$500
$1,000
$2,500
(Wind & hail claims are $1,000 deductible)
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| Current insurance carrier (if applicable): |
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| *Have there been any claims or losses on the home in the last 5 years: | |
| If so, list type, date and amount paid: | |
| *Do you have any pets? If so, please list type: | |
| Bite history: | |
| *Do you have an alarm system? If so, is it direct reporting or monitored: | |
| The following are optional coverages. Please select the ones you may be interested in: |
Back up of sewer & drain (covers damage caused by water from a drain or sump pump that backs up into the home) A must for homes with basements.
Earthquake (this adds back the exclusion of this coverage.)
Scheduled property such as jewelry, furs, art work, musical instruments
Recreational vehicle coverage such as snowmobile, 4-wheeler or jet ski |
| *Date of birth: | |
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