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Conrade Insurance Offices

129 E. Broadway
Newton, KS 67114-0547

Phone: 316-283-0096
Fax: 316-283-2444

info@conradeinsurance.com

Applicant Information

Name:
Social Security:

Please provide for accurate quote
Current Street Address:
City:

 

State:           Zip:  
Address of Insured Location

(if same as above, enter "same")
City:  
State             Zip: 
County:
E-Mail Address:  
Home Phone:
Work Phone:

Home Information
Year of Construction:

 

Total Square Ftg:

No. of Stories: Type of Garage:
Type of Roof: Date of Last Roof Work:
Substructure: Finish of Substructure: %

Check all that apply:

Attached Wood Deck?    If yes: Approx. Sq. Footage of Deck
Central Heating & Air?
Wood Burning Stove?  If yes, is it professionally installed?
Fireplace?  If yes, what type:
Pool? If yes, what type:
Trampoline?
Deadbolt Locks on front and back entries
Centralized Alarm System (monitored for burglary, fire, etc?)
Smoke Detectors
Balcony? If yes: Approx. Sq. Footage of Balcony
Num. of Baths:
Heat System:
Type of Dwelling:
Type of Construction:

Frame: Constructed of wood frame, covered with wood or vinyl. Less than 50% of exterior is brick or stone.
Masonry Veneer: 50% or more of the exterior is brick or masonry but has wood frame construction.
Masonry: Constructed entirely of face brick, common brick, stone or split block.
Is daycare provided on the property premises? Yes   No
Do you own a dog(s)? Yes   No
If yes, list breed(s)
Distance to nearest fire hydrant in feet: Ft
Miles to nearest fire department: Miles
Updates to Electrical: (year)

Amps
Updates to Plumbing: (year) Updates to Heating: (year)
Any customization to home (built-ins, marble counter tops, etc.)?
Please Describe:

Losses or claims for this property in the past five years?
Please Describe:

Present Insurance Carrier:

Expiration Date of Current Policy:

 (mm/dd/yy)

Current Annual Premium:

Coverage Amounts
Amount of coverage requested on dwelling:  
Amount of coverage requested for personal liability:  

Amount of deductible requested:

  
Closing Date:  
Purchase Amount:  
Secret Word:
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Phone: 316-283-0096
Toll Free: 888-283-0096
Fax: 316-283-2444

129 E. Broadway, Suite 200
P.O. Box 547
Newton, Ks 67114-0547

ClientConnect

www.conradeinsurance.com
info@conradeinsurance.com

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