Walker Insurance Agency

General Information:

Your Name:

Telephone #:

E-mail Address:

Mailing:

Street Address:

City: State: Zip:

Property (to be insured):

Address:

City: State: N.C. Zip:

Coverage Amounts:

Dwelling Coverage $:

Personal Property Coverage $:

Liability Limits $:

Medical Payments $: per person

Deductible Amount $ per occurrence

Any scheduled property (jewelry, coins, collectables, furs, etc.)

Construction and Other Information:

Year of construction:

Dwelling Construction: Frame Brick/Masonry

Is there a swimming pool on the premises? Yes No

Fire District (if known):

In City Limits Yes No

What city?

Previous Insurance History:

Any losses in last 5 years: Yes No

If yes, describe the loss . . .

Current Homeowner's
Insurance Company:

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