Inland Marine Application Billings Mutual Insurance

INLAND MARINE APPLICATION Class of Property: (Only Personal Items. Property for a trade or profession is Prohibited.) Guns Jewelry Personal Effects Musical Instruments

Answer all of the following questions.

1. Applicant's Name______SSN ______- ______- ______D.O.B.______

2. Other family permanently residing with applicant______

3. Residence Address: ______STREET CITY STATE ZIP CODE COUNTY

4. Occupation______Business Address ______

5. Is applicant engaged, in any way, with professional entertaining ? YES NO If Yes, explain in REMARKS below.

6. Does anyone, other than owner, have interest in the property? YES NO If Yes, explain in REMARKS below.

7 .Do you have or intend to have another policy providing coverage on this property YES NO

8. Primary Company dwelling / contents policy number is ______Company ? ______

9. Amount of Insurance needed $ ______Policy term from ______to ______

REMARKS: ______

SCHEDULE OF ARTICLES: Attach copy of Bill of Sale or Appraisal AMOUNT DESCRIPTION (Include Model & Serial No.) MANUFACTURER COST OF INSURANCE ______$ ______$ ______$ ______$ ______$ ______$ ______$ ______$ ______$ ______$ ______$ ______$ ______$ ______$ ______$ ______$ ______$ ______$ ______

APPLICANT’S STATEMENT The undersigned warrants and represents and agrees that statements herein are made with respect to me and all members of my household for the express purpose of inducing the Company to issue an insurance policy and these statements and answers are true, correct and complete to the best of my knowledge. I understand that any binder or insurance policy issued as a result of this application will be based on the facts and answers stated. I understand that if any payment remittance by or on my behalf is not honored by the payer (bank) it will be deemed nonpayment of policy and no coverage will be afforded. The undersigned authorizes the Company to perform a general investigation including a credit investigation of the applicant(s) for purposes of this insurance coverage. I have read this application before affixing my signature.

APPLICANT’S SIGNATURE ______DATE ______

AGENT’S STATEMENT I certify that I have asked all questions on this application and the answers as indicated are those given to me by the applicant who signed the application.

AGENT’S SIGNATURE ______Agency No. ______DATE ______