Bishop Insurance Service ~ Home Insurance

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How did you here about us?

Personal Information:

Applicant's Name:

Co-Applicants Name:

First Name:

Last Name:

Phone Number:

000-000-0000

Date of Birth:

Marital Status:

Marital Status::

SSN: (000-00-0000)

Mailing Address:

City:

State:

Zip Code:

Dwelling Address:

City:

State:

Zip Code:

Property Information:

Primary Use:

Occupied By:

Number of Families:

Year Built:

Total Square Footage not including basement:

Number of Stories:

Construction Type:

Roof Type:

Any Farming on Premise

Yes No

Number of Acres:

Number of Bathrooms:

Number of Bedrooms:

Ground Floor Sq Footage:

Primary Heat Source:

Basement Square Footage:

	Finished	Unfinished	Walkout
Sq Footage

Garage:

Number of Cars	Attached	Detached	Built-in

Current Insurance Company:

Policy Number:

Number of Years/Months:

Yrs. Mos.

Current Coverage Amount:

Deck

Square Footage:

Porch

SQFootage:

Type:

Fireplace:

Number of:	Chimneys	Hearths	Gas

Woodstove:

Chimney Type:	Fireplace	Insert

Pool:

In Ground	Above Ground	Fence

Hot Tub

In Ground	Above Ground	Fence

Animals

Dogs	Dog Breed	Cats	Other

Outbuildings

Square Feet:

Updates:

A/C	Smoke Alarms	Fire Extinguishers	Dead Bolts

Hardwood Floors	Hardwood Trim	Palladian	Bed Bath Combo

Trampoline	Visible to Neighbors	Under Course of Construction	Under Renovation or Reconstruction

Distance to Fire Hydrant (Feet)	Distance to Fire Dept (Miles)	Scheduled Property

Updates:

	Wiring	Plumbing	Heating	Roof
Year
Full or Partial
Year Inspected

Losses in the last 5 years:

If Yes, Date , Description, and Amount Paid.

Bankruptcy:

Any business conducted on the premise?

Yes No

If Yes, Please Describe

Additional Comments:

Bishop Insurance Service © 2006-2012
302 1st St W Ste 102 · Polson · (406) 883-5372
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(406) 883-5372