C L Butcher Agency
P.O. Box 5449
Knoxville, TN 37928
(865) 689-5482
Fax: (865) 689-5491

Request for Home Insurance

* Required Fields

Effective Date:
Your Name:
Your Mailing Address:
City:
State:
Zip:
*Email Address:
Daytime Phone:
Choose One:
Current coverage
Company:
Expiration Date:
Type of policy desired:
Amount of insurance desired
Homeowners only
What is the value of your home?:
Valuation of Home:
Liability Limit:

Condo/Renters only
What is the value of your personal property?:
Personal Property Valuation:
Medical Payments::


Deductible:
Property Information
What is the construction type of your home?:
In what year was your home built?:
In what County/Township are you located?:
Distance to the nearest fire hydrant?:
What kind of pets do you have?:
Do you have a swimming pool?:	Yes No
Do you have a trampoline?:	Yes No
Do you use a wood burner?:	Yes No
Smoke Detector(s) Installed:
Home Security System Installed:

Home Updates: Enter year updates were made. If year not known, enter "unknown":
Roof:
Plumbing:
Wiring:
Heating:

Optional Property Coverages
Earthquake Coverage Requested:
Flood Coverage Requested:
Sewer/Water Backup Coverage Requested:

Property Floaters - Indicate limits below
Antiques:
Coins:
Computers:
Fine Arts:
Furs:
Jewelry:
Stamps:
Tools:
Other Floater Coverage / Limit:
Describe Previous Loss Information (Date / Type / Amount):
Additional Comments:
Please click the Send button only once.