E-mail: info@tankreainsurance.com

870.425.6363


 

 

 

 

 

 

 

 




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Tank Rea Insurance Agency
  Serving Your Insurance Needs Since 1947!
 

Application For Homeowner / Automobile Insurance - Not a Binder

Complete the application below and press submit. Pressing reset will erase all the fields and allow you to start over. A representative from Tank Rea Insurance will contact you. **Required fields

APPLICANT'S NAME AND MAILING ADDRESS (Include county and ZIP)
Telephone Number SSN Date of Birth 

Homeowner / Condominium / Renter Section
Homeowner Condominium Renter Dwelling or Personal Property Coverage Limit $
Frame Stone Veneer Masonry Veneer
Aluminum/Vinyl Other 		Deductible
$ 		Scheduled Personal  Property
Earthquake Coverage
Other
Year Dwelling Built
Sq Ft (living area)   		Fire District
Do You Have A... Deadbolt Smoke Detector Fire Extinguisher Central Alarm
Woodburning Stove Swimming Pool, Fenced? Yes No
Has applicant had a foreclosure, repossession or bankruptcy during the past five years? Yes No
Any losses during the last three years? If yes, indicate below:

Automobile Section
Garage Location If Different From Above (Include county and ZIP)
Year - Make - Model - Body Type

(1)

(2)

(3)

(4)

VIN Number

(1)

(2)

(3)

(4)

Usage: Pleasure Work* Business *Miles One Way Annual Mileage
Liability Coverage Limit $ Medical Payments Coverage Limit $
Uninsured / Underinsured Motorists Coverage Yes No
Comprehensive Coverage Deductible $ Collision Coverage Deductible $
Towing Coverage? Yes No Transportation Expenses? Yes No
Driver Information
Name Sex Marital Status Vehicle Driven Relation to Applicant Date of Birth Occupation
(1)
(2)
(3)
(4)
Has any driver above had an accident or moving violation within the last three Years? If yes, indicate below.
Name of Prior Automobile Insurance Carrier:
I would like to be contacted by phone by e-mail
**E-Mail Address:


 

Compensation Disclosure Notice

Tank Rea Insurance Agency
 PO Box 450
Mountain Home, AR 72654
Phone: (870) 425-6363 Fax: 870-425-9155
 Email: info@tankreainsurance.com

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Last Updated: 01/23/2010 Copyrighted All Rights Reserved