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	Florida Residence: Please contact Sunshine State Insurance Company at www.ssic-insco.com
	Name Address City State Ohio Zip Code Home Phone - Best Time to Call Work Phone - Fax Phone - E-Mail Type of Policy Select One Home Owners Renters Dwelling Insurance Current Insurer Does your policy renew within 12 days? Yes No Is this quote for a new home purchase? Yes     No Closing Month     Day RESIDENTIAL DATA Homeowners Amount of coverage on dwelling (ie.100,000) $ Renters/Condos Amount of coverage on personal property (ie. $25,000 - Minimum $10,000) $ ZIPCODE of Property Deductible Amount $100 $250 $500 $1000 Construction Type Frame Masonry Other Design Type # of Stories 1 2 3 4 Basement Yes No Square Footage Garage Type No Garage 1-Car Attached 2-Car Attached 1-Car Detached 2-Car Detached Fire Station Within 1 mile Within 5 miles Within 10 miles Within 25 miles Year Built Approximate PLEASE CHECK ALL THAT APPLY Smoke Detectors Fire Extinguisher Swimming Pool Tennis Court Wood Burning Stove Central Burglar/Fire Alarm Dead Bolts Non Smokers CLAIM / LOSS INFORMATION Please describe any Claims or Losses you've had in the past 3 years

Sunshine Insurance Agency | 213 South Sandusky Avenue | Upper Sandusky, OH 43351 | 419.294.4638 | fax 419.294.4694
Sunshine Insurance Agency | 130 1/2 Water Street | PO Box 452 | Prospect, OH 43342 | 740.494.9448 | fax 740.494.9879