Applicant Info
	All risks must be insured to 100% of market value.
	Applicant Name:
	First Name:		Last Name:
	Protection Class:	- Select - 1-6 7-8 9-10	Construction:	- Select - Frame Masonry
	Occupancy:	- Select - Owner Rental Seasonal	Number of Units:	- Select - 1 2 3 4
	Risk Location:	- Select - City of Indianapolis La Porte Lake County Porter St. Joseph All Other Counties	Was Dwelling built before 1900?	YesNo
	Dwelling's Value:		Deductible:	- Select - $250 $500 $1,000 $2,500 $5,000

	Coverage Options
	Related Private Structures (max of 50% of Coverage A value):				YesNo
	Personal Property Coverage:				YesNo
	Personal Liability: YesNo    - Select - $25,000 $50,000 $100,000 $300,000
	Owners, Landlords and Tenant's Liability: YesNo    - Select - $25,000 $50,000 $100,000 $300,000
	Medical Payments: $500 $1,000
	Additional Living Cost or Fair Rental Value limit chosen: YesNo
	Supplemental Heating:				YesNo
	Vandalism & Malicious Mischief:				YesNo
	Unrelated Named Insured:				YesNo
	Residence Burglary (owner occupied and rental only): YesNo
	Earth Movement Coverage:				YesNo
	Mine Subsidence Coverage:The limit available is $200,000.				YesNo	- Select - Clay Drawford Daviess Dubois Fountain Gibson Greene Knox Lawrence Martin Monroe Montgomery Orange Owen Parke Perry Pike Posey Putnam Spencer Sullivan Vanderburgh Vermillion Vigo Warren Warrick

Specialty Underwriters Group - P.O. Box 36385 Cincinnati, OH 45236  -  800-844-1815