Big Lake Office - 763.263.0785
Elk River Office - 763.390.4872
E-Mail - info@istmn.com
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We're an independent insurance agency representing many insurers.
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Your Info
First Name
Last Name
Email
Phone
Secondary Phone
How did you find us?
Web Search
Referral
Other
If you choose 'Referral', who referred you?
Current/Prior Insurance
Are You Currently Insured ?
Yes
No
Current Insurance Provider
AIU Insurance
Allmerica Fin'l Benefit Ins Co
Allstate Insurance
Allstate Indemnity
American and Foreign Ins Co
American Bankers Ins Co of FL
American Deposit Insurance
American Home Assurance Co
American International South
American Mfrs Mutual Ins Co
American Motorist Ins Co
American National P & C Co
American Premier Insurance
American Protection Ins Co
AMEX Assurance Company
Amica Mutual Insurance
Atlanta Casualty Company
Atlantic Mutual Insurance Co
Auto-Owners Insurance Co
CGU Insurance
Charter Oak Fire Insurance
Cincinnati Insurance Co
Colonial Penn Franklin Insurance
Dairyland Insurance
Deerbrook Ins
Electric Insurance Company
Esurance
Federal Insurance Company
Fidelity & Casualty Co of NY
Fidelity & Guaranty Ins Undrs
First Floridian Auto and Home Insurance Company
First Liberty Insurance Corporation
First National Ins Co of Amer
GEICO General Insurance
GEICO Casualty Company
GEICO Indemnity Company
General Accident Insurance
Government Employees Insurance
Hartford Accident & Indem Co
Hartford Casualty Ins Co
Hartford Fire Insurance Co
Hartford Ins Co of Midwest
Hartford Ins Co of Southeast
Infinity Insurance
Integon General Ins Corp
Integon Indemnity Corp
Integon National Insurance Co
Integon Preferred Insurance Co
Kemper Insurance
Liberty Insurance Company
Liberty Mutual Fire Insurance
Lumberman's Mutual Casualty Co
Massachusetts Bay Ins Co
Merastar Insurance Company
Metropolitan Casualty Ins Co
Metropolitan Prop & Cas Ins Co
Metropolitan General Ins Co
MIC General Insurance Corp
National General Assur Co
National General Ins Co
National Interstate Ins Co
Nationwide Mutual Fire Insurance
Nationwide General Insurance
Nationwide Assurance
New Hampshire Indemnity
Omni Indemnity
Omni Insurance
Owners Insurance Company
Pacific Indemnity Company
Progressive Casualty Ins Co
Prudential Prop & Cas Ins Co
Regal Insurance
Response Insurance Company
Royal Ins Co of America
SAFECO Ins Co of America
Sentry Insurance Mutual Co
St Paul Guardian Ins Co
State Auto Prop & Cas Ins Co
State Farm Fire & Cas
State Farm Mutual Auto
Superior Insurance Company
Teachers Insurance Company
TIG Indemnity Company
Travelers Indem Co of Amer
Twin City Fire Insurance Co
United Services Auto
United States Fid & Guar Co
USAA Casualty Insurance
USAA General Indemnity
Victoria Fire & Casualty Co
Windsor Insurance
Worldwide Insurance Company
Present company not listed
If not listed please write here
Length of time with current insurer
Less than a year
1+ year
2+ years
5+ years
10+ years
When Does The Current Policy End?
/
/
Property Information
Address
City
State
Zip
Distance to Fire Station
Less than 5 Miles
5-10 miles
Over 10 miles
Distance to Hydrant
under 1000 ft.
over 1000 ft.
Year Built
Property Use
Primary
Secondary
Seasonal
Rental
Farm
Vacant
Occasional occupied
Type Of Property
Single Family Home
Townhome
Condo
Mobile Home
Finished Sq. Footage
Number of Families
1
2
3
4
Stories
1
2
3
4
Property Values
Purchase Date
/
/
Replacement Value
Construction/Heating
Type of Construction
Frame
Brick
Brick Veneer
Pre-Fab
Other
Type of Roof
Asphalt
Wood
Tile
Gravel
Other
Age of Roof
Type of Electrical
Copper
Aluminum
Other
Type of Heat
Gas
Electric
Oil
Liquid Propane
Coal
Wood Stove
# of Fireplaces
# of Bathrooms
Protection Devices
Burglar Alarm
None
Local
Central
Direct
Fire Alarm
None
Local
Central
Direct
Smoke Detectors
Each Room
Not Sure
Fire Sprinkler System
Not Available
Partial
Full
Basement
Basement Sq. Footage
Finished Basement Percentage
not finished
25
50
75
100
%
Garage
Garage Type
Attached
Detached
No Garage
How many car garage?
1
2
3
4
Other Structures
Swimming Pool
None
In Ground
Above Ground
Swimming Pool Fence
None
Plastic/Vinyl
Metal
Steel
Diving Board
Yes
No
Trampoline
Yes
No
Applicant Information
Date of Birth
/
/
Marital Status
Married
Single
Divorced
Separated
Domestic Partner
Years At Current Address
Social Security Number (optional)
-
-
Credit Rating
Excellent
Average
Poor
Number of Dogs
Are they an attack breed
Yes
No
What type?
Akita
Doberman
German Shepard
Pit Bull
Rotweiler
Other
Co-Applicant Information
First Name
Last Name
Date of Birth
/
/
Years At Current Address
Social Security Number (optional)
-
-
Additional Information - Discounts
Have you had any reported losses during the past 3 years?
Yes
No
If Yes, please put date of loss
Type of Loss
Weather
Fire
Theft
Water
Any business conducted on premises(including day care)?
Yes
No
Does you own any recreational vehicles (snowmobiles, dune buggies, mini bikes, atvs, etc)?
Yes
No
Basic Coverages
Dwelling
Limits
Personal Liability
100,000
200,000
300,000
Medical Payments
1,000
2,000
3,000
Deductibles
All Perils Deductible
250
500
1000
2000
