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Name
Address
City
State Zip
 
Home Phone
 		Business Phone
 		 
Fax Number
 		E-Mail
 		 
Automobile
Vehicles (Yr., Make, Model, 2 Dr. or 4 Dr.)
4 x 4
Cost New
Miles to Work
(1-Way)
Special Features


Safety Credits

Vehicle
Theft System
Anti-lock Brakes
Air
Bag
Passive Restraints
VIN #


Driver Information

Name
Male or Female
Married or Single
Date of Birth
Social Security
Smoker
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Accidents/Traffic Violations
(Last 3 years)
Driver
Date
What Happened
 
 
 
Coverages
Limits
Bodily Injury
 
Property Damage
 
Medical Payments
 
Comprehensive Deductible
 
Collision Deductible
 
Uninsured/Underinsured Motorists
Towing Yes No
 
Rental Reimbursement
Yes No
DATE CURRENT POLICY EXPIRES:

Current Insurance Co.:

Home Owners/Renters
Home Owners
Brick or Frame Yr. Constructed Smoke Alarms Wood-burning Stove
Yes No Yes No
Deadbolt
 Alarm System
 Fire Exit
 Central Station Reporting
Yes No Yes No Yes No

 
Renters

Brick or Frame Units in Building Current Policy Expires: Current Insurance Company:

Additional Coverages and Value
(Extended Liability, Jewelry, Boats, Waterbed Liability, etc.)

Life and Health Insurance

Name: Smoker: Yes No
Date of Birth:
 Male/Female:
Amount of Life Insurance:
Health Insurance Deductible:
Current Health Insurance Company:

   
   
Middendorf Insurance Associates, Inc.
8400 Hickman Rd. | Clive 50325
(515) 252-1414
6011 Grand Ave. | Des Moines 50312
(515) 279-5984
5526 NW 86th St. | Johnston 50131
(515) 331-6536
517 8th St. SE | Altoona 50009
(515) 967-4427
E-Mail: info2@middendorfins.com