Applicant Info
	Applicant Name: First:		Last:
	Protection Class:	- Select - 1-6 7 8 9 10	Construction:	- Select - Frame Masonry
	Risk Location:	- Select - Bell Breathitt Carter Clay Elliot Estill Floyd Harlan Jackson Johnson Knott Knox Laurel Lawrence Lee Leslie Letcher Magoffin Martin Menifee Morgan Owsley Perry Pike Powell Rowan Whitley Wolfe Other	Occupancy:	- Select - Owner Rental Seasonal	Number of Units:	- Select - 1 2 3 4
	Dwelling's Value:		Deductible:	- Select - $250/10% surcharge $500/Base $1000/7% credit $2500/14% credit $5000/20% credit
	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: - Select - $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:(Some counties are mandatory for coverage - maximum value is $100,000 or the Coverage A value)				YesNo	- Select - Bell Boyd Breathitt Butler Carter Christian Clay Davies Elliot Edmonson Floyd Greenup Hancock Harlan Henderson Hopkins Jackson Johnson Knott Knox Lawrence Lee Leslie McCreary McLean Martin Morgan Mulenberg Ohio Perry Union Webster Whitley Wolfe Other
	Number (if any) Claims paid in the last 3 Years:				- Select - 0 1 2 3 or more

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