Insurance Agency, inc.   
330 May Mart Drive
Rochelle, IL  61068
(815) 562-4152 		Independent Insurance Agents of America













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*Since our agency's focus is on professional, personable service,  we must limit our customer range to Illinois customers only.

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Fill these fields out to obtain accurate pricing, any indication of rates provided are subject to underwriting, verification of information and acceptance by the Insurance Company. 
   

   
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Home Insurance -  Underwriting Information
   

STORIES CONSTRUCTION FOUNDATION ROOF
1-Story 
1 1/2-Story 
2-Story 
Split Level 
Bi-Level		 Frame or Stucco 
Masonry
Masonry&Frame 
Frame&Masonry		 Basement 
Crawl Space 
Slab 
Family Room or Den		 Asphalt Shingle 
Wood Shingle 
Tile or Slate 
Other 
Age of Roof 

   

Policy Type
# of Units
Year Built Square Feet
Year Purchased
Purchase Price
Plumbing Year 
Last Update		 Drains
Electrical System Last Update
Central Alarm
Heating Last Update
Central Air
# of Fireplaces
# of Bathrooms
Garage # of Car Garage
Size of Decks
Swimming Pool
Flood Area
Mine Subsidence
Area

    

Prior Losses Past 5 Years
Bankruptcy Ever Filed

   

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Current Insurance Information
      

Insurance Carrier
Expires
Deductible

 

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Current Insured Values

Dwelling Personal Liability
Personal Property Medical Payments
Personal Injury Scheduled Property
Flood Coverage Other Coverage 
(Business/Hobby/Farm)

   

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Other Coverage or Special Needs
   



   
 

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