Name	Date of Birth
Occupation	Marital Status
Spouse	Spouse Date of Birth
Spouse Occupation	Address to be insured
City	State
Zip	County
Present Address ( if different)
Home Phone	Work Phone
Year Built	Roof Type
Construction Type ( Frame, etc )	Amount to insure
Additional Personal Property	Other Structures Amount
Miles from Fire Dept	Sq foot on Lower Level
Stories	Personal Liability Amount
Smokers ? Deadbolts	Alarms ? Smoke Detectors ?
Porch ?	Garage ? Attached ?
Basement ?	AC ? Type of Heat
How do you want to be contacted? (Phone, Mail, E-Mail,...)	E - Mail Address ?

Please note that completion of the following request for information does not constitute the purchase of insurance. No coverage may be added, changed or bound as a result of submitting this request for information or quotation of insurance. All coverage must be confirmed by the agency in writing subject to an acceptable signed application meeting the underwriting guidelines of the Insurance Company. The Davidson Agency is licensed in the states of Kansas and Colorado. No solicitation of insurance is being made outside of these states.