Waddell Insurance Group

Inland Marine Insurance Quote

Information

Please fill in all of the requested information and an agent will contact you immediately with your quote as well as answer any of your insurance related questions.

Employer Name: (Required)

Name: (Required)

Address: (Required)

City: (Required)

State: (Required)

Zip Code: (Required)

E-Mail Address:

Phone Number:

Fax Number:

Occupation:

Length of Time at Current Job?

Social Security Number:
(Not Required, but some of our insurance companies can't quote without it)

Dwelling Information

Name of Current Carrier:

Date Current Policy Expires:

Amount of Current Insurance?

How Long at Current Address?

Number of Families Living in Dwelling

Deductible

Liability

Is This your Primary Residence?
Yes No

Any Claims in Past 3 Years:
Yes No

If Yes (To claims in the past 3 years), Please Enter Date of Loss, Amount of Loss and Cause of Loss:

Home Construction Information

Square Footage, Heated and Cooled:

Year Home was Built:

Number of Stories:

Construction of Home:

Foundation:

Smoke Detectors?
Yes No

Burglar/Fire Alarm?
Yes No

Is Alarm Monitored?
Yes No


Coverages
Property	Amount of Ins	Rate	Premium
Jewelry
Furs
Fine Arts
Cameras
Musical Instruments
Silverware
Stamps
Coins
Golf Equipment
Personal Computers

General Information
Protective Devices/Systems in use? Yes No
Will any property be exhibited? Yes No
Will any special restriction/endorsements apply? Yes No
Will any type of deductible apply? Yes No
Is any property used professionally/commercially? Yes No
Any other Insurance with this company? Yes No
Has any loss occurred during the last 3 years? Yes No
Any coverage declined, cancelled or non-renewed during the last 3 years? Yes No

Any Comments You Feel May be Helpful to us in Providing You with This Proposal:

How May We Contact You?
Email Fax Telephone

Best Time to Call?
AM PM

Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me.

I have read and agree with the above disclaimer (It is mandatory to check box before submitting)

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