Please tell us if you are new to Behnke & Associates or an existing client  Select One New Existing

Please provide the following contact information:

Is the home we are insuring different than the address listed above?

If yes, please give us the address that should be insured:

Enter your occupation in the space provided below.

Enter your employer in the space provided below.

Date of Birth:  -- mm/dd/yy

Social security number (without dashes) 

Enter your spouse or co-owner's name in the space provided below:

Enter occupation for spouse or co-owner in the space provided below:

Enter your spouse or co-owner's employer in the space provided below.

Date of birth spouse or co-owner:  -- mm/dd/yy

Spouse or co-owner's social security number: 

In what year was your house built: 

What is the living square footage? 

Type of home:  Select One Dwelling Condo Townhome Villa Other

Type of roof:  Select One Shingle Tile Flat Other

Age of roof? 

Use of property:  Select One Primary Secondary Tenant

Is there any business conducted on premise?  Yes No

If yes, please explain:

Name of Subdivision or Association: 

Unattached structures to be insured?  Yes No

If yes, please explain:

Do you have a mortgage on this property?  Yes No

If yes, then please provide your mortgage company information.

What is your loan number? 

Do you have a second mortgage on this property?  Yes No

If yes, then please provide your second mortgage company information.

What is your loan number for your second mortgage? 

Have you made any recent improvements to your home?  Yes No

Select any of the following improvements you have made:

Kitchen           Heating or A/C    Electrical        Windows              
Gargage or carport     Swimming Pool      Bathroom       Plumbing             
Roof       Patio or Deck      Addition or Extension     Other            
 

Please describe any of the improvements selected and give the year of completion?

Do you own or lease any of the following:

Boat         Fine Art         Jewelry         Computer and Software
Firearms       Golf Cart     RV         Silver / Silverware 
Furs        Snowmobiles      Collectibles       Cell phone or pager 
Other                 

If yes, then please give a brief description, the estimated value and any additional details:

Which alarms or protection do you have for your home?

Fire alarm - Notifies a central station     Burglar alarm - Notifies a central station 

Fire alarm - local alarm only               Burglar alarm - local alarm only 

I have deadbolts on all exterior doors     

Please describe any other security devices you have:

Select the following only if your answer is YES:

I have a wood-burning stove or a similar secondary heating unit.        I own one or more rental properties. 

I have an unfenced swimming pool.      I have a fully fenced in swimming pool. 

I have a diving board or a trampoline.     I have dogs on my property. 

I employ domestic help, such as a nanny, maid, gardener, etc. 

I am interested in the following extra coverages:

Automobile Insurance                    $1,000,000 (or higher) Liability Umbrella  Business Insurance

Low-Cost Term Life Insurance        Health Insurance              Retirement Planning 

Motorcycle, RV, Snowmobile, Golf Cart           Boat Insurance         Flood Insurance   

College Savings Plan        Personal Income Protection           Long-term Care 

Mortgage Protection Insurance 

I am interested in information on the above protection. Please contact me by:

Email         Regular Mail       Home Phone        Work Phone