WMQuoting
Home
1859 MUTUAL QUICK QUOTE
200 E Main St PO Box 157, Woodville, OH 43469
Phone: 419-849-2521, Fax: 419-849-3518
General
Agency:
Profit Center:
Effective Date:
Agent Email Address:
to send a copy of this Quick Quote Form
Primary Insured
Insured's Name:
Mailing Address:
Mailing Address(2):
Mailing Address City:
Mailing Address State:
Select One
AL
AK
AZ
AR
AS
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
RI
SC
SD
TN
TX
TT
UT
VT
VA
WA
WV
WI
WY
Mailing Address Zip Code:
SSN:
-
-
DOB:
Add Second Insured
Second Insured
Second Insured's Name:
Second Insured's SSN:
-
-
Second Insured's DOB:
Risk Location
Use Same Address as Insured
Address:
Address(2):
City:
State:
OH
Zip Code:
County:
Policy Type:
Select One
Home Protector
Farm Protector
Rental
Seasonal
Tenant Homeowner
Tenant Farm
Deductible:
Select One
$2,500
$5,000
$7,500
$10,000
$25,000
Occupancy:
Select One
Owner Occupied
Tenant Occupied
Vacant
Dwelling Under Construction
Dwelling Under Renovation
Property Coverages
(a) Dwelling:
$
%
(b) Private Structures:
$
%
(c) Personal Property:
$
%
(d) Additional Living Expense:
$
%
Construction:
Select One
Masonry
Frame
Mobile Home
Square Foot:
# of out buildings
Select One
None
1
2
3
4
5
6
7
8
9
10+
Liability Coverages
Liability:
Select One
None
$100,000
$300,000
$500,000
$1,000,000
Medical Payments:
Select One
$1,000
$2,000
$3,000
$4,000
$5,000
Photos
Add Photo
Carrier Questions
Has Applicant ever filed for Bankruptcy?
Select One
Yes
No
Has Applicant ever been convicted of any Felonies?
Select One
Yes
No
Is the Property For Sale or in Foreclosure?
Select One
Yes
No
Has Insurance ever been Cancelled, Non-Renewed or Declined?
Select One
Yes
No
Has the Applicant ever had any Fire Losses?
Select One
No
1 Fire Loss
2 or More Fire Losses
Solid Fuel Appliance?
Select One
No Solid Fuel Appliance
Indoor Solid Fuel Appliance
Outdoor Solid Fuel Appliance
Mobile Home Approved Park?
Select One
Not-Applicable
Approved Park
Non-Approved Park
Any Student Occupancy?
Select One
Yes
No
Any stairs with rise over 24 inches with no hand railing?
Select One
Yes
No
Unknown
Are there uneven steps or porches with uneven wear?
Select One
Yes
No
Unknown
Any primary open outside stairway to 2nd floor apartment?
Select One
Yes
No
Are there any Solar Panels on the Premises?
Select One
Yes
No
Are there any Dog(s) on Premises?
Select One
Yes
No
# of Dogs?
Select One
1
2
3
4
5
6
7
8
9
10+
Breeds:
Is there a Swimming Pool/Pond on Premises?
Select One
Yes
No
Diving Board/Slide?
Select One
Yes
No
Any Baby-Sitting or Day Care for pay?
Select One
Yes
No
Backup of Water?
Select One
Yes
No
($500 Increments from $2,500 up to $15,000):
$2,500
$3,000
$3,500
$4,000
$4,500
$5,000
$5,500
$6,000
$6,500
$7,000
$7,500
$8,000
$8,500
$9,000
$9,500
$10,000
$10,500
$11,000
$11,500
$12,000
$12,500
$13,000
$13,500
$14,000
$14,500
$15,000
Service Line/Equipment Breakdown $5000?
Yes
No
Is there a Trampoline on the Premises?
Select One
Yes
No
Trampoline Anchored and Netted?
Select One
Yes
No
Any Business Pursuits performed on Premises?
Select One
Yes
No
Is this Property Subject to any Homeowners/Condominium Owners Association agreement?
Select One
Yes
No
Additional Hazards? (Ex: knob & tube wiring, fuel oil heat, etc.)
Select One
Yes
No
Describe:
Has the Applicant had any Losses in the last 5 Years?
Select One
No
1 Loss
2 Losses
3 Losses
4 or more Losses
Date
Amount Paid
Description
Loss #1:
$
Loss #2:
$
Loss #3:
$
Loss #4:
$
Notes
Disclaimer
By checking this box, you understand that 1859 Mutual uses information from you and other sources, such as claims and credit histories, to determine eligibility for your insurance. New or updated information may be used to determine your renewal. Submission of this information does not constitute the company consent to bind. Its Privacy Policy explains how 1859 Mutual discloses and protects your personal information and how you may access and correct it.
Submit
Submit
Error
×
There was a problem with your submission. Please correct all items highlighted in red and try again.
Show Error Details
Upload Images
×
You must select a valid image and add a caption in order to proceed
Select Image:
Caption:
