Independent Insurance Services of Central Iowa
Homeowners Insurance Application

Thank you for visiting the Website of Independent Insurance Services of Central Iowa Are you seeking homeowners insurance? We're here to help you. Please provide the information required below, submit the form, and we'll respond with a quotation.

This page is secure, but if you are concerned about sending personal information over the Internet,  feel free to print this form, fill it out, and mail it or fax it to us. Our mailing address and fax number are at the bottom of the form.
I'd prefer to receive my insurance quote by:
 

FAX E-mail Telephone
 
My FAX number is: 
My e-mail address is: 
I'd like an agent 
to call me at: 
 
My mailing address is:
 
Name: 
Street Address: 
City: 
State: 
  Zip:  -
 
Location of property (if different than mailing address):
 

Street address: 

  

City: 

  

State: 

  Iowa      Zip: -

 

Is the dwelling located within 1000 feet of a fire hydrant? 

Yes  No 

How many miles to the responding fire department?
  miles
Occupancy
How many families occupy this dwelling?  
Who lives in the dwelling?  
What part of the year is the dwelling occupied?  
Is this home a condo?   Yes   No 
Is business conducted on the premises?   Yes   No 

Describe any business conducted on these premises.
Is any farming conductions on these premises?   Yes   No 
 
Additional Considerations
Do you have one or more dogs?   Yes   No 
If you have one or more dogs, please list the breed(s).  Dog 1

 Dog 2

 Dog 3

Does any of your dogs have a bite history?    Yes   No
Do you have any livestock or exotic pets?    Yes   No
Do you have a swimming pool on the premises?    Yes   No
Do you have a trampoline on the premises?    Yes   No
Do you have a wood, oil, or kerosene stove?    Yes   No
Structure
Year the home was built:  
Roof covering:  
Year roofing shingles were last replaced:  
Garage Type:  
Garage Capacity (Number of Cars):  
Number of Full Bathrooms:   1    2     3    4   5  
Number of Half Bathrooms:   1    2     3    4   5  
 
Additional Home Features
 
Number of Fireplaces: None   1    2     3    4 or more  
Number of Decks: None   1    2     3    4 or more  
Services
Has the plumbing ever been replaced?  
If plumbing has been partially or totally replaced, in what year was the work done?  
   
Type of electrical service panel:  
Number of amps in the electrical service:  
Has the electrical wiring ever been replaced?  
If electrical wiring has been partially or totally replaced, in what year was the work done?  
   
Has the heating or air conditioning been updated?   Yes   No 
If heating or air conditioning has been replaced, in what year was the work done?  
   
Security Features
Does your home have any of these security features? Check each feature that is currently installed in your home.
  Fire Extinguishers  
  Smoke Detectors  
  Deadbolt locks  
  Local Burglar Alarm  
  Local Fire Alarm  
  Central Station Burglar Alarm. Police department is directly alerted.
  Central Station Fire Alarm. Fire department is directly alerted.

Deductible and Coverage Amounts

We will calculate the replacement cost value of your home based
on the information you have given us in the previous sections.

We also need the following information to help us give you
the most accurate homeowners insurance quote.

 
Current Homeowners Policy
   
Please refer to your current policy to complete this section.
   
Policy Deductible:  
   
Coverage A: Dwelling structure amount  $
Coverage B: Other structure replacement  $
Coverage C: Contents or personal property  $
Coverage D: Additional living expenses  $
Liability Coverage Amounts
Please fill in your current coverage amount or the amount of coverage you would like.

Personal Liability 

  

Medical Payments

  

 
Additional Coverages
 
Do you need earthquake coverage? Yes  No
 
If you need coverage for scheduled personal property, please indicate the amount desired.

Jewelry    

  $

Silver       

  $

Furs         

  $

Cameras   

  $

Computers

  $
 
Underwriting Questions
Do you currently have insurance on this
dwelling?		   Yes  No
Why are you interested in homeowners
insurance?		  
How soon will you want this insurance
to be effective?		  
Have you filed for bankruptcy in the last 
5 years?		   Yes  No
Your social security number is necessary to run a financial responsibility report which many insurance companies now require for an accurate quote.

We are committed to protecting your privacy. We use SSL technology to safeguard your personal information.
What is your social security number?  
What is your birthday? (mm/dd/yyyy)  
What is your occupation?  
Are you married? 
   Yes  No
If you are married, what is your spouse's name?  
What is your spouse's social security number?  
What is your spouse's birthday? (mm/dd/yyyy)  
What is your spouse's occupation?  
How many homeowners claims have you filed in the last five years?  
Please give the date and description of any claims.

 
 
Please add any additional information or comments here.

Notice of Insurance Information Practices

Personal information about you may be collected from persons other than you. Such information as well as other personal and privileged information collected by us or our agents may, in certain circumstances, be disclosed to third parties. You have the right to review your personal information in our files and can request correction of any inaccuracies. A more detailed description of your rights and our practices regarding such information is available upon request. Contact your agent or broker for instruction on how to submit a request to us.

Please click the Submit button to send this request for a
homeowners insurance quote to
Independent Insurance Services of Central Iowa, Inc.  Thank you.

Independent Insurance Services of Central Iowa
11 East Church Street, Marshalltown, Iowa 50158
Telephone: (641) 752-4618
FAX (641) 753-0557