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First name

Last name

Phone

Address (include house #, street, city, state & zip code)

Asking Price of Dwelling or Current Dwelling Coverage Amount

Age of roof (place NA if unknown)

Detached Garage &/or Shed on Property (List how many if coverage is needed; place NA if not wanted)

Age of roof for Detached Garage/Shed

Personal Property Coverage amount wanted (Min of $50k; itemized list req with $100K+ in coverage (place "do not want" if this coverage is not wanted) [Personal Property is for what is inside your home; appliances, furniture, clothing, etc]

Liability Coverage (Yes or No) Liability insurance coverage protects you financially if you're responsible for someone else's injuries or property damage

Have you had any insurance property claims in the last 3 years? If Yes, please explain.

Items valued over $2k (jewelry, firearms, farm equipment, etc) (Place NA if not needed; list items and value)

Service Line Endorsement (Yes or No) Service Line provides up to $6,000 for loss or damages resulting from a service line failure)

How did you hear about German Farmers Insurance?

Provide for us any other information we may need to know about the property (closing date of purchase, intended effective date, etc). Please indicate if this property is a farm here and our agent will be in contact about any farm equipment needing to be insured.

Thanks! Our agents perform a property inspection on every property, we will complete as soon as possbile and have quote to you shortly.

German Farmers Mutual Assessment Insurance Association of Hall County, Inc/The

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