(402) 228-9300 Beatrice, NE

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Contact Name *

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Date of Birth

Occupation

Property Location Under Construction

Address

City

State

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County

Mailing Address / Current Address

Address

City

State

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County

Insurance Information

Deductible Desired

Amount of Liability Desired

Hurricane Coverage Desired?
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Earthquake Coverage Desired?
Yes No

Windstorm Coverage Desired? (not applicable in all states)
Yes No

Dwelling Information

Estimated Replacement Cost

Square Footage

Roof Type

How Many Floors?
1 Story
1.5 Story
2 Story
Bi-Level
Tri-Level
Other

Type of Construction
Wood
Stucco
Masonry
Brick Veneer
Aluminum Siding
Other

Other Home Features (check all that apply)

Dead Bolts

Fire Extinguisher

Located within 5 miles of Fire Station

Located 1000 feet from Fire Hydrant

Home Located within City Limits

Claims

Date of Claim

Amount Paid

Claim Type

Description

Note: Coverage Can Not Be Bound Changed Or Deleted Via Electronic Message

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Beatrice Insurance Agency | 800 Court St | Beatrice, NE 68310 | (402) 228-9300

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