Perry County Mutual Insurance Company
218
West Ste. Maries St.
Perryville,
MO. 63775
(573) 547-6633
FAX (573) 547-1035
Full
Name_____________________________
Address_______________________________
City___________________________
State______ Zip Code___________
Phone
( )__________________
Preferred Calling Time AM PM
Best Time_______
(please circle one)
Alt.
Phone (
)___________________ Preferred Calling Time
AM PM
Best Time_______
(please circle one)
E-mail_________________________________
Type
Of Home Single
Family _____
Mobile Home _____
Year
Your Home Was Built __________
Square
Footage Of Living Space ____________ sq. ft.
Construction
Type Frame _____ Brick Veneer _____
Roof
Type Asphalt
Shingle ____ Wood Shingle ____ Tile/Slate ____ Metal ____
Age
Of Your Roof _________ year(s)
Do
you live on more then (1) one acre of land?
Yes No
If yes, How much? ________ acres
Present
Coverage
Dwelling
$______________ Other Structures $_____________ Loss Of Use $_____________
Personal
Property $_____________ Liability Limits $_______________
Medical
Payment Limits $_______________
Optional
Coverage (please check for any
additional information)
Earthquake
_____ Replacement Cost/Personal Property_____ Sewer Backup _____
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