Bill & Barb Afryl 847-640-1400, Illinois Auto Insurance for the Active Family

Home Insurance - For Residents of Illinois Only

Please make an effort to complete to the best of your ability all the
areas that you can.

Full Name
Address
City
County
State Zip
Work Phone
Home Phone
E-Mail
Currently Insured?    Yes  No
With what specific company:    

How long with this company:    

Please indicate any insurance concerns you might have.

Basic Information Regarding Your Home;

If Not a Single Family Residence Choose Type Here:


Do You Reside In The Structure:
Yes No

Year built:


Fire protection class:
(if known)

Distance To Fire Hydrant:
(in feet)

Distance To Nearest Responding Fire Department:
(in miles)

Smoke Alarms:           
Yes No

Fire Extinguisher:     
Yes No

Central Station Alarm: 
Yes No

Dead Bolts:            
Yes No

Inside City Limits:    
Yes No

Construction Material:


Roof Type:


Coverage Limits

Liability Limits:


Current Insured value of home:


Deductible:

General Information

 

Have you had any homeowner claims or losses
within the last 3 years? If so, please explain:

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I understand that this service merely provides a proposal request and is not a Policy of Insurance, Application or Offer to Insure on behalf of any Insurance Company, Agency or Agent. Individual companies reserve the right to accept, reject or modify a proposal after investigation and review.

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