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Pierre

124 W Dakota
Pierre SD 57501

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Miller

427 N Broadway
Miller SD 57362

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Customer Name:*

First Last

Address*

Street Address City State ZIP Code

Do you own or rent?:*

Own

Rent

Do you have a Mortgagee?

Yes

No

Who is your mortgage through?

Martial Status?:*

Married

Unmarried

Spouse Name:

First Last

Spouse Social Security #:*

Spouse Date of Birth:*

MM slash DD slash YYYY

Home Phone:

Work Phone:

Cell Phone:

Social Security Numbers for all named Insured’s:

First insurer SS#:*

Second insurer SS#:*

Third insurer SS#:*

Fourth insurer SS#:*

Current Insurance Company:

Expiration Date:

Month

Day

Year

How long with current company?:

Claims in the last 5 years:

Fireplace?:

Yes

No

What type of fireplace?:

Gas

Propane

Wood

Pellet

Basement?:

Yes

No

What percent is finished?:

Number of 1st floor bathrooms?:

Number of 2nd floor bathrooms?:

Number of basement bathrooms?:

Type of Roof?:

Age of Roof?:

Any updates since new?:

Last Replaced?:

Air conditioning?:

Central Air

Window Unit

None

Type of heat?:

Natural Gas

Propane

Oil

Electric

Other

Type of Siding?:

Other Siding Type:

Own a Boat or Jet Ski?:

Boat

Jet Ski

None

Garage Information:

Attached

Detached

None

Type of Roof:*

Age:*

Do you have any Jewelry or Guns that would need extra Coverage?:

Measurements of the house and all out buildings

Home Total Square Footage:

Garage Total Square Footage:

Other Total Square Footage:



Pierre

124 W Dakota
Pierre SD 57501
605-224-0707



Miller

427 N Broadway
Miller SD 57362
605-853-7774

De Smet Farm Mutual

Pierre Location

124 W Dakota
Pierre SD 57501
605-224-0707

Miller Location

427 N Broadway
Miller SD 57362
605-853-7774

De Smet Farm Mutual

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