Homeowners | KLH Insurance Baton Rouge Insurance Agency

Insured Name:

First Last

Date of Birth:

Occupation:

Spouse Name:

Spouse Date of Birth:

Occupation:

Phone Number:

Agency Name:

Agent Name:

Phone Number:

Email*

Current Insurance Carrier:

(If lapsed/canceled/non-renewed enter last date of coverage)

Effective Date Requested :

Location Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Options1

Options2

Primary

Secondary

Secondary/Rental

Short-Term Rental

Annual Rental

Builders Risk

Vacant

Dwelling Limit:

Liability:

Personal Property:

Medical Payments:

Other Structures:

Loss of Use:

AOP Deductible:

Hurricane Deductible:

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