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Home Owner
Applicant Name
Phone Number
Email Address
Address Line 1
Address Line 2
City / State / Zip
Co/Plan
Policy #
Account #
New     Renewal
Effective Date
Expiration Date
Direct Bill     Agency Bill
Payment Plan
 
  
Previous Residence (If less than 3 years)
Location of Property if Diff From Above
APPLICANT INFORMATION
Occupation Employer Yrs Emp Mar Stat Date of Birth Social Security #
Applicant
Co-Applicant
 
RATING/UNDERWRITING
Material Type Frame Masonry Masonry Veneer Aluminum Siding Plastic Siding Superior Other:
Year Built
Market Value
Heat Type    Central Heating? Yes No
Within City Limits Yes     No
Within Fire District Yes     No
Within Prot Suburb Yes     No
 
LOSS HISTORY
List all losses during the past 3 years
Date Type Description of Loss Amount
 
BINDER

41 South Main Street
Post Office Box 20
Winchester, KY 40392-0020
Office: 859-744-2200 * Facsimile: 859-744-2130
800-456-5502

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