Klemme Insurance Services, LLC

Dwelling Binder

Please Complete The Dwelling Binder Request

Date of Request:
*
Quote #:
Closing Date:
*

Buyer's Information
Buyers Name:
*
Buyers Social Security #:
*
Buyers Date of Birth:
*
Buyers Phone #:
*

Co- Buyers Name:
Co- Buyers Soc. Sec. #:
Co- Buyers Date of Birth:

Address Information
Mailing Address (If Different from the Property Address):
*
Mailing City:
*
Mailing State:
*
Mailing ZIP:
*

Property Address:
*
Property City:
*
Property State:

Property ZIP:
*
County:
*

Property Information
Amount of Coverage:
*
Contents Coverage:

Liability Coverage:

Construction Type:

Roof Type:

Year Built:
*
Number of Stories:
*
Square Footage:
*
Year Roof Replaced:
*
Condition of Roof:

Responding Fire Department:
*
Miles to Fire Dept.:

Distance to Fire Hydrant:

Is dwelling and premises maintained in an insurable condition?:

Occupancy:

Occupied by more than one family:

Pets:

Business on the premesis:

Wood Burning Stove:

Pool:

Trampoline:

Comments:
Comment

IMPORTANT
Trader Name:
*
Premium Escrowed?:

Mortgage Company Address:
*
Mortgage Company City:
*
Mortgage Company State:
*
Mortgage Company ZIP:
*
Trader Phone:
*
Trader Fax:
*
Trader Email:
*
Delivery preference:

Comment
Security code:
*
Do not enter anything in this field:

* indicates a required field

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