(360) 352-1897 Montesano, WA

Backholm Insurance

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Current Insurance Information

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Earthquake Coverage Desired?
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Windstorm Coverage Desired? (not applicable in all states)
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If Any Pets, What Breed?

Dwelling Information

Is this home owner occupied or a rental?
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Is Your Home over 20 Years Old? If so, What Updates Have Been Made?

Age of Hot Water Heater?

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Type of Construction
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Dead Bolts

Smoke Detectors

Fire Extinguisher

Central Station Fire Alarm

Central Station Burglar Alarm

Located within 5 miles of Fire Station

Located 1000 feet from Fire Hydrant

Swimming Pool

Trampoline

Home Located within City Limits

Claims List any claims in past 3 years:

Date of Claim

Amount Paid

Claim Type

Description

Date of Claim

Amount Paid

Claim Type

Description

Date of Claim

Amount Paid

Claim Type

Description

Personal Property Estimated value of your personal property:

Jewelry & Watches

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Fine Arts and Breakable Items

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