Please fill in the information below and use the submit button to send to our office. This information is sent via a secure server to protect your privacy. If you prefer, you may print this form and mail it to the address below.

NOTE: All Fields Are Required. If you don't want to enter your Social Security Number, enter 000-00-0000 in the SS# area and we will call you for that information.
Name Spouse's Name
Date of Birth Date of Birth
Social Security # Social Security #
Occupation Occupation
Address City State
Zip Code   County
Daytime Phone Cell Phone
E-mail Deeded in your name?   Yes   No  
Dog(s)?  Yes   No Breed(s)  Bankruptcy in past 5 years?  Yes   No  
Distance to Fire Department miles    
Year Built Year Purchased
Construction Style
Square Footage Garage  Size     Finished?
Foundation Fireplace
Ext. Walls Wall Finish    
Type of Roof Ceiling    
    Baths Full      Half 
Outbuildings Deck Sq. ft? 
Heating Air Conditioning  
Swimming Pool Porch   Sq. ft.
Basement  Skylights  
Basement Sq. ft. finished     :  
Plumbing Year Wiring Year
Roof Year HVAC Year
Building Details
Floors - please choose percentage for each Finished Attic: Yes No  Finished Sq. ft.
Carpet, Acrylic Ceramic Tile French Doors (count each)  
Carpet, Wool/Berber Marble Spiral Staircase  
Hardwood Vinyl Business/Office on Property?  Yes     No   
Laminate Concrete Details:
Parquet Rubber      
Click the box in front of any of the following that you have:
Central Vacuum Solar Heat Hot Tub Intercom
Sauna Sprinker System Burglar Alarm Jacuzzi
Stained or Varnished Woodwork Hardwood, Slate, Marble or Quarry Tile Floors Brick or Stone Walls >50%
RV, ATV, Golf Cart, Snowmobile Computer Custom Installed Vanity Elevator
Satellite Dish Wet Bar Cabana Gazebo
Built-In Barbeque Basketball Court Trampoline Lift Chair or Wheelchair Lift
Do you have any of these special features? Check all that apply.
Den Exercise Room Laundry Room Rec Room
Office Formal Dining Room Large Foyer Study
Library Cathedral Ceilings >70 ft. Great Room Family Room
Type details here:
If you have any of these BUILT IN , please use the drop down list to indicate the quality:
Air Conditioner Air Filter Carbon Monoxide Detector
Air Exchanger Elevator Roof Exhaust Fan
Humidifier Garage Door Opener Sauna
Bathroom Heater Hot Tub (not jetted tub) Trash Compactor
Refrigerator Intercom System Video Door Answering System
Ceiling Fans Sprinker System Washer
Central Vacuum Jetted Tub Water Purification System
Countertop Range Microwave Water Softener
Dishwasher Oven Wet Bar
Water Heater Fireplace insert Whole House Fan
Dryer Range Hood    
Current Policy # Dwelling Replacement Cost (on existing policy)
Current Company Cancelled or Non-Renewed in past 5 years? Yes   No
Claims in Last 5 years?     Yes   No Auto Company  
If yes, please explain:   Renewal Date
Current Liability Limit $
Current Policy #

Mailing Address for Form:

Laura Yerk
Illnois Alliance Insurance
421 East Grant Hwy.
Marengo, IL 60152