Benchmark Insurance Agency, Inc.

207 E 500 S.

Bountiful, Utah 84010

801-397-3434

Fax: 801-951-0050

Email:

To receive an accurate quote, all information should be included.
Please supply an e-mail, fax, mailing address or call
(801) 397-3434

Name:    

Address: 

City, State, Zip:

Telephone:   

E-mail:

Requested Effective Date:

Quote for Homeowners, Flood or Condominium.

Property Location (Address):	Nearest Cross Street:
Year Built:	Number of units in your section:
Brick       Frame	Community #: (if known)
Dwelling Coverage Limits: $	or Unit Owners Building Limit: $
Contents Coverage Limit: $
Primary Heat Source:	If oil, is tank in ground:    Yes     No
Square footage of living space: (if known)	How many floors?
Is there a basement:     Yes      No	Is building elevated?  Yes  No
Built on Pilings?   Yes    No
Schedule of Personal Property:
Jewelry Limit: $    Fur Limit: $     Fine Art: $

Quote for Boat.

Year	Manufacturer
Length	Model
Number of Engines	Horsepower
Type of Fuel
Navigating Area:	Laid Up From  To
Inboard	Outboard
I/O	Top Speed
Purchase Price $	Insured Value  $
Liability Limit  $
Years of Boating Experience	Years as Boat Owner
Boating Education

Please print out and fax or email to the address or Fax number at the top of form

.