Perry County Mutual Insurance Company

218 West Ste. Maries St.

Perryville, MO. 63775                                

(573) 547-6633                               

FAX (573) 547-1035                                 


                                                            Home Insurance Quote Request                                  


Full Name_____________________________                                      


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)       



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 _____                                                            

Thank you for taking time to fill out this quote request. We will contact you upon receipt.