KING & BRIM INSURANCE, INC.
Your Independent Agents For A Lifetime
 

Family-owned and operated and serving metro Atlanta since 1953!
  Home ● Auto ● Life  
  Business ● Health  
  770-522-9411  


Use our SECURE site to get a quote on coverage for your home, health, auto & life.  We will NEVER sell or misuse your information.

  Homeowners Insurance  
 
 How did you find us?
 Applicant:
 Applicant D.O.B. (Required)
 Drivers License #:
 Street:
 City:
State:    Zip:
 Inside City Limits?:

County:    

 Home Phone:

CellPhone:   

 Work Phone:
 Best time to contact: Preferred method of contact:
 E-mail Address:
 How long have you been at this address?   

Previous address IF at current address for less than 1 year:
  Street:
  City:
 State:    Zip:
 
 Prior Insurance Carrier:
 Expiration Date:    
 
 
Residence Information		  
 
 Type of Residence:
 Year Constructed:

  Square Footage: 

 
 Number of Bedrooms:

 Number of Bathrooms:  

 Roof Replaced?:

 Year Roof Replaced:  

 Type of Construction:    
 Do you have a basement?

 Is the basement finished?  

 
 
Protection Devices		  
   Smoke Detectors

Fire Extinguishers

 
   Dead Bolts

Central Fire Alarm

 
   Sprinklers

Central Burglar Alarm

  
 
Coverage		  
   Dwelling Limit: $ Loss of Use: $  
   Liability Limit: $ Medical Pay Limit: $  
   Personal Contents Amount  $  
   Deductible Amount  $  
 
High Value Items (Enter $ amount)		  
   Jewelry

Silver

Cameras

Furs

  
   Fine Arts Other:  
     
 

Comments:

 
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