GWINN INSURANCE
"Your Hometown Insurance Agency Since 1912"
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Name of Applicant:
Date of Birth:
Sex:
Address:
City:
State:
Zip:
Phone #:
Email Address:
Occupation:
SS#:
Driver License #:
Name of Spouse:
Spouse D.O.B.:
Spouse Occupation:
Spouse SS#:
Spouse Driver License #:
Height:
Weight:
Are you a US citizen?
Yes
No
Have you smoked in the past 12 months?
Yes
No
Have you smoked in the past 24 months?
Yes
No
Have you ever had heart disease or a disorder, angina, stroke, diabetes, high blood pressure, or cancer?
Yes
No
Are you taking any medications?
Yes
No
If yes please list:
Are you currently unemployed, retired, laid off, or collecting disability?
Yes
No
Amount of life insurance wanted: $
Name of Applicant:
Date of Birth:
Sex:
Address:
City:
State:
Zip:
Phone #:
Email Address:
Occupation:
SS#:
Driver License #:
Name of Spouse:
Spouse D.O.B.:
Spouse Occupation:
Spouse SS#:
Spouse Driver License #:
Household Memebers:
Youthful Drivers:
Tickets in past five year?
Yes
No
If yes please list:
At Fault Accidents or Claims Paid:
Yes
No
If yes please list date damage and amount:
Health Insurance?
Yes
No
If yes, Health Insurance Provider:
Current Auto Coverage:
Yes
No
If yes please list carrier:
If yes please list current BI Limit:
Year:
Make:
Model:
Vin Number:
PLPD only:
Yes
No
Comprehensive Deductible:
$0
$100
$250
$500
Collision Deductible:
$0
$100
$250
$500
Collision Type:
Broad
Regular
Add Another Vehicle
Add Another Driver
Second Driver D.O.B.:
Second Driver License #:
Second Driver Occupation:
Year:
Make:
Model:
Vin Number:
PLPD only:
Yes
No
Comprehensive Deductible:
$0
$100
$250
$500
Collision Deductible:
$0
$100
$250
$500
Collision Type:
Broad
Regular
Name of Applicant:
Date of Birth:
Sex:
Address:
City:
State:
Zip:
Phone #:
Email Address:
Occupation:
SS#:
Name of Spouse:
Spouse D.O.B.:
Spouse Occupation:
Spouse SS#:
Household Memebers:
Responding Fire Department:
Miles to Fire Department:
Feet to Hydrant:
Year Home Built:
Sq. Footage:
Number of Stories:
Foundation:
Basement
Crawl Space
Slab
Finished Basement Percentage:
Foundation Material:
Stone
Concrete
Block
Wood
Other
Siding:
Vinyl
Aluminum
Clapboard
Wood
Log
Other
Roofing:
Asphalt
Steel
Other
Garage:
None
Attached
Detached
Car Port
How Many Cars:
1
2
3
4+
Heat Source:
Natural Gas
Radiant Heat
Wood
Electric
Other
Wood Stove:
Yes
No
If yes, location:
Fire Place:
Yes
No
Air Conditioning:
Yes
No
Deck/Porches:
Yes
No
If yes, size:
Number of Bathrooms:
1
1.5
2
2.5
3+
Updates, provide year
Wiring:
Heating:
Plumbing:
Roof:
Three Wall Addition:
Yes
No
If yes, year built:
Any claims against current policy in the past five years:
Yes
No
Deductible:
50
100
250
500
1000
