Liebert Partner Rewards

QUOTES FOR NORTH CENTRAL OHIO

Personal Information

Name

Address

City

State

Zip Code

Home Telephone

Alternate Telephone

Best Time to Call

Morning

Afternoon

Evening

Automobile Information

Present Insurance Company

Expiration Date

Annual Premium

Vehicles in Household

Year

Make

Model

Vin #

Annual
Milage

Business

Yes

Drivers in Household

	Name	Age	Married/ Single	Relationship	Occupation
1
2
3

Driving History (Past Five Years)

Has any driver had his/her license suspended or revoked?

Yes

If yes, please explain who, when, and why:

Any accident or moving violations in the past five years whether you or someone else was at fault? Please list driver, date of incident and type of incident

Please list all fire, theft, glass and/or vandalism losses:

Property Information

Present Insurance Company

Expiration Date

Annual Premium

Current Liability Limits

Property

Renters

Condominium/Co-Op

Home

Yr Built

Style

Sq Footage

Basement

% Complete

Garage

Attached

Detached

Construction (Choose One)

Wood

Brick Veneer

Solid Brick/Masonry

Aluminum/Vinyl

Log Home

Manufactured Home

Type of Heat

Oil

Gas

Electric

Wood/Coal/Pellet

Other

Protection Devices (Check all that Apply)

Smoke Detector

Fire Extinguisher

Dead Bolt Locks

Monitored Fire Alarm

Monitored Burgular Alarm

Other Information

Feet From Hydrant

Miles to Fire Station

Any Losses in the past five years? If yes, please explain Losses past Five Years

Request Information

Personal Article Floater (Jewelry, Furs, Fine Arts, Etc)

Boat Yacht Insurance

Personal; Liability Protection

Flood Insurance Click here for additional Information (PDF Format)

Replacement Cost Estimate of your Home

Special Programs for Employees, Associations, Affinity Groups

Commercial Insurance

Life Insurance

Health Insurance

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