Homeowner Policy Service Form - Klump Insurance Agency, LTD. of Missouri




Klump Insurance Agency, LTD.
"We do the shopping for you"

2864 Sugartree Lane
Maryland Heights, MO 63043
314-739-1346
314-739-1360 (fax)
E-mail:JeffKlump@SBCGLOBAL.NET

Homeowner /Condo/Tenant Policy Service Request

The following request does not guarantee coverage or a coverage change. This information will be acknowledged from our office within 2 business days following this request. Authorized staff from our office will confirm any changes and inform you of the effective date and time of your change.

All required fields must be answered in order for this request to be processed.
Name (REQUIRED) Last 4 digits of your policy number (REQUIRED) Day Phone (REQUIRED) Night Phone (REQUIRED) Best time to call (REQUIRED) E-Mail Address
Address Change Street County City, State, Zip Is this a new location or a mailing change only Current Homeowner Coverages Changes Dwelling Amount Property Coverage Deductible Comprehensive Liability Amount Medical Payments Guaranteed Replacement Cost Coverage Water Backup Coverage Earthquake Coverage Personal Property (contents), Outbuilding Coverage, Additional Living Expenses are calculated from the dwelling amount. Current Condo/Tenant Coverages Changes Contents Amount Property Coverage Deductible Comprehensive Liability Amount Medical Payments Guaranteed Replacement Cost Coverage Water Backup Coverage Earthquake Coverage New home information Purchase Price Replacement cost Don't know, call me Settlement Date (approximately) Type Of Home Construction Year house built Type of Alarm Number of Stories Ground floor square footage Shape of house (number of corners) 3 Wall Addition? (square feet) Total basement area (square feet) Percent finished Attached Garage Number of Bathrooms Family Room Sun Room Den Separate Dinning Room Number of Fireplaces Hardwood Floors Central Air Decks ( total square feet) Porches (total square feet) Large Laundry Room Large foyer Central Vac Video entry system Sauna Hot tub Jaquzzi bath Dishwasher Trash Compactor Range hood Garbage disposal Sprinklers?

Mortgagee Information New Mortgagee Change of Address Mortgagee name & address Provide mortgage clause verbatim from mortgagee Delete mortgagee
Please have someone call me with the following information about my Home policy? I would like information on the following additional coverages Auto Life Boat Health Disability Income Long Term Care Commercial Vehicles Business CoverageIRA annuities

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Page Created 6-6-01 Latest Revision

Name (REQUIRED)
Last 4 digits of your policy number (REQUIRED)
Day Phone (REQUIRED)
Night Phone (REQUIRED)
Best time to call (REQUIRED)
E-Mail Address

Address Change
Street
County
City, State, Zip
Is this a new location or a mailing change only

Current Homeowner Coverages Changes
Dwelling Amount
Property Coverage Deductible
Comprehensive Liability Amount
Medical Payments
Guaranteed Replacement Cost Coverage
Water Backup Coverage
Earthquake Coverage
Personal Property (contents), Outbuilding Coverage, Additional Living Expenses are calculated from the dwelling amount.

Current Condo/Tenant Coverages Changes
Contents Amount
Property Coverage Deductible
Comprehensive Liability Amount
Medical Payments
Guaranteed Replacement Cost Coverage
Water Backup Coverage
Earthquake Coverage

Mortgagee Information
New Mortgagee	Change of Address
Mortgagee name & address Provide mortgage clause verbatim from mortgagee
Delete mortgagee

Please have someone call me with the following information about my Home policy?
I would like information on the following additional coverages	Auto Life Boat Health Disability Income Long Term Care Commercial Vehicles Business CoverageIRA annuities