Personal Inland Marine Insurance Quote

Cooper, Simms, Nelson, & Mosley World Wide Web Site Online Insurance Application


		IMPORTANT NOTICE: Please note that no coverage can be bound using e-Mail, the Internet, or by leaving a voice mail message. All requests must b conducted through our agency with signed applications.


Toll Free: 1.877.644.2766 Providing Insurance Since 1934


Personal Inland Marine Insurance Quote		We would like to provide you with a free, no-obligation insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Personal Information
Applicant's Name:
Address:
City:	State: Zip:
Day Phone:	Night Phone:
Best Time To Call:	AM PM
Email Address:

Applicant & Location Information
Age:	Marital Status: M S	Occupation:	Spouse's Occupation:	Territory Code:	Protect Class:	Fire District/ Code #:
Location of Property (if different from above): Additional Location			Dwelling Type(s):	Construction Type(s):		# Families (in each):
			Other:

Coverages

Please indicate additional property that is not listed in boxes 10-14

Property

Amount of Ins.

Property

Amount of Ins.

Jewelry

Coins

Furs

Golfer's Equipment

Fine Arts

Cameras

Musical Instruments

Silverware

Stamps

Unattended Car Coverage (Stamps/Coins)
Broad Form Pair & Set Coverage
Non-Mobile Organ Coverage
Safe Credit (Identify Property, Safe Class, Etc)

ACV Loss Settlement
Replacement Cost Loss Settlement
Breakage Coverage (*On Schedule)
Blanket Coverage

Additional Rating Information

General Information
Explain All "Yes" Responses in Remarks	Yes/No	Explain All "Yes" Responses in Remarks	Yes/No
1. Any protective devices/systems in use?	Y N	6. Any other insurance with this company?	Y N
2. Will any property be exhibited?	Y N	7. Did any loss occur during the last 3 years?	Y N
3. Will any special restriction/ endorsements apply?	Y N	8. Any coverage declined, cancelled or non-renewed during the last 3 years? Not applicable in MO	Y N
4. Will any type of deductible apply?	Y N	Prior Insuror & Policy Number
5. Is any property used professionally/ commercially?	Y N	Prior Insuror & Policy Number
Remarks

Schedule of Property
#	Provide a detailed description of each item, from whom purchased, etc. Be sure to forward all required appraisals/bills.	Purchase/ Appraisal Date	Amount of Insurance
			$
			$
			$
			$
			$
			$
			$
			$
			$
			$
			$
			$
			$
			$
Please use the "Additional Comments"* section at the bottom of this form for any additional entries.*

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, such as additional coverages, schedule of property, etc..., please enter them here.

Please click on the "Submit Quote" button to send your quote request.
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