Jefferson County Insurance & Financial Services, Inc.
92 & 59 Hwy.
Oskaloosa, KS 66066
785-863-2261
FAX 785-863-2390
email JCI

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(close Homeowners section) Current Insurance Information
Insurance Company Name: (NOT* Insurance Agency/Broker)*
Policy Exp. Date:		Amount Insured for:
Mortgage Amt:		Premium Amt:
Term:		Any Claims in Last 3 years?
General Information About Your Home
Year Home Built:		Total Square Feet:
Yrs @ present address:
Liability coverage:		Market Value:
Distance to nearest fire hydrant:
Distance to nearest fire department:
Home Type:		Home Construction:
Roof Type:		Garage Type:
Age of roof:		Garage:
# of Bedrooms:		# of Fireplaces:
# of Bathrooms:		Exterior:
Foundation:		Basement Finished?
		If finished, what %?	%
Additional Information
Swimming Pool?:	No Yes	Pool Fenced?:	No Yes
Diving Board?:	No Yes	Trampoline?:	No Yes
Smoke Detector?:	No Yes	Heating System:
Security System:		Fire Alarm:
Replacement cost of personal items:
Any business conducted in home:
List values of any jewelry, furs, or specialty items:
List pets & breeds:
Do you want to include Flood Insurance?:

(close Auto section)
Year, make and model of auto:
Is this vehicle currently insured?:	No Yes
Primary vehicle use:
Zip code where vehicle is usually kept:
Own or lease
Add another vehicle?

(close Auto 2 section)
Year, make and model of auto:
Is this vehicle currently insured?:	No Yes
Primary vehicle use:
Zip code where vehicle is usually kept:
Own or lease
Add another vehicle?

(close Auto 3 section)
Year, make and model of auto:
Is this vehicle currently insured?:	No Yes
Primary vehicle use:
Zip code where vehicle is usually kept:
Own or lease
Add another vehicle?