Are you married *

Yes

No

Number of Bath Rooms *

Please fill out complete as possible so the proper analysis can be made.

City *

Market Value(if owner)

Comments

Type of Coverage Desired *

Address 2 *

Best time to call *

Day Time

Evening

Number of Occupants *

Amount of Coverage Requested(renters $10k minimum) *

Basement *

Yes

No

Purchase Price(if owner)

Purchase Date(if owner)

Garage Size

Last Name

Garage *

Yes

No

HOME AND RENTERS INSURANCE

Number of Bed Rooms *

Date of Birth

Number of Units in Building(renter)

Zip Code *

Last Name *

Number of Occupants(renters)

Phone

Address 1 *

State Issued *

SS#

Spouse/Partner First Name

1-800-910-3292

First Name *

Driver License # *

State *

Driver License #

SS# *

Date of Birth *

BATTLES AND ASSOCIATES

INSURANCE AGENCY