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McCaleb Insurance Agency

662-746-1100

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FILL OUT THE FOLLOWING AND SUBMIT FOR A HOME QUOTE

NAME:

ADDRESS:

ZIP:

STATE:

CITY:

OCCUPATION:

PHONE:

EMAIL:

CONFIRM EMAIL:

CURRENTLY INSURED?

If yes, list carrier and # of years continuous.

HOME ADDRESS:

ZIP:

STATE:

CITY:

COUNTY:

DESCRIPTION OF RISK:

CONSTRUCTION:

SQUARE FEET:

YEAR BUILT:

# OF STORIES:

AGE OF ROOF:

DISTANCE TO FIRE STATION:

MARKET VALUE: $

AMOUNT OF COVERAGE:

MILES

A. DWELLING $

B. OTHER STRUCTURES $

C. PERSONAL PROPERTY $

D. LOSS OF USE $

E. PERSONAL LIABILITY $

F. MEDICAL PAYMENTS $

UNDERWRITING QUESTIONS:

1. Is Risk in city limits:

2. Is Risk within 1000 feet of a fire hydrant?

3. Is Risk vacant or unoccupied?

4. Is Risk occupied by more than one family?

5. Is business conducted in Risk?

6. Any previous losses on any properties in the past five years?

7. Any previous fire losses?

8. Has risk been cancelled, nonrenewed, or declined by another company?

9. Is there a wood buring stove located in the risk?

If yes, is the stove correctly installed?

10. Have you filed bankruptcy in the last five years?

11. Any animals?

If yes, please list:

12. Is there a swimming pool on the premises?

BIRTHDAY: