Commercial Insurance Underwriter

CIU

Commercial Insurance Underwriters, Inc.
A Surplus Lines Agency
www.ciusgf.com
901 E. Saint Louis St. #205
Springfield, MO. 65806-2537

 

Personal Lines Quick Quote Sheet

 

Date *Name Insured

SSN1 DOB1

*Agency/ Producer Name

SSN2 DOB2

                   *Phone / Fax

                *Email Address

 

Home Owners

Dwelling Owner

  

*Address

Dwelling Tenant

Dwelling Renovation

  

*City, State

Mortgage                 

Dwelling Seasonal

Dwelling Vacant

  

Dwelling

Mortgage Name ò

Tenant Short Term

Builders Risk

  

Adj. Structures

HO-4

MonoLine\Earthquake

  

Contents

HO-6

    

L.O.R./A.L.E.

Replacement Cost (If Eligible)?         

 

Liability

Protective Class 

 

Med Pay

Construction Type

 

Vacant

Length of Vacancy 

# of Families 

 

Vacant Reason

Square Footage

 

Existing Fire Damage

Year Built

 

Fire Damage Comments

# of Stories 

 

Do any of the following hazards exist?  Trapoline     Lake Pond     Dock

       Swimming Pool     Wood Burning Stove     Farming or Hunting Activities

# of Acres 

 

Reason for coming to CIU

             Updated                                 Date

  

*Prior Current Carrier

Wiring

 

*Expiration Date

Plumbing

 

Deductible

Heating

 

Bankruptcy          If yes, discharge date 

Roof

 

Bankruptcy Reason
   

Losses                         List Below...

Animal on premises

    

# of Animals Breed

   

Bite History

   

 

Date of Loss

Description / Cause

Amount

 

 

 

Before You Submit To Us, Make Sure You Fill in the RED Areas.  We Also Recommend Printing a Copy!!

TO COMPLETE YOUR APPLICATION, COMPLETE THESE TWO STEPS:
1.  Please select your Personal Lines Account Executive:

2.  Hit this Submit button.