DIC EZ App

For Fast service on your DIC accounts complete the form below. Your submission will be electronically delivered to the next available underwriter.

Coverage Requested Applicant Name Location Address: Applicant's Primary Telephone Number: Date of Birth:

Have there been any losses at the property Paid or Not by the Insurance, during the last 3 years? If yes, please provide loss details. Has applicant had any policies or coverage's cancelled or non-renewed in the past three years? Has the Insured (s) had a Foreclosure, Repossession, Bankruptcy, Judgement or Lien during the past five years? Any Farming or Other Business Conducted on Premises (Including Day/Childcare)? Expiring Carrier: Willing to Renew?: If No, why?: Renewal Quote: $ Target Premium: $ Premises Liability: $ Medical Payments: $ Dwelling Coverage: $ Occupancy: Square Footage: Protection Class: Other Structures: $ Personal Property Coverage: $ Loss of Use: $ Number of Families: Structure Type: Deductible: $ Sprinkler?: Roof Material: Year Built:

Is the structure a Mobile or Manufactured home? Yes No

Is Building 100 percent on Circuit Breakers?: If over 20 years old, provide building updates for Wiring (Yr), Roof (Yr), Heating/Air (Yr) & Plumbing (Yr): Primary Heat Source: Does the Dwelling have 150 feet of brush clearance from all sides of the structures?:

Agency Information:

Agency Name: Contact Person: Phone Number: E-Mail Address: