To: O. B. COURTNEY & ASSOCIATES, INC.
P. O. Box 43772, Seven Points, Texas 75143-8511
Phone:  903/432-2954 or 800/873-6266  ~  FAX:  903/432-3276 or 888/269-6600

Insured ___________________________________________________________________________
Address To Be Inspected:
No. 1 ___________________________________________________________________________

Occupancy: _______________________________________________________________________

No. 2 ____________________________________________________________________________

Occupancy: ______________________________________________________________________

TYPE OF COVERAGE:
____Fire, E. C., V & MM
____Dwelling(Short Form)
____Homeowners (Short Form)
____TMP/SMP/TBOP/TCPP
____OL & T
____Manufacturers & Contractors
____Comprehensive General Liability
____Garage Liability/Dealers Open Lot/GKL
____Commercial Auto (Limousine/Trucker/etc)
____Burglary and /or Robbery
____Inland Marine (state type of coverage)
_______________________________________________
____Diagram
____Other ________________________________________________________________________
____Special Attention:_______________________________________________________________
_________________________________________________________________________________

AMT. OF COVERAGE:

Bldg. No. 1 _________________ Contents_________________

Bldg. No. 2 _________________ Contents_________________

Premium Base: (please check)
Area _______________________
Payroll ______________________
Receipts _____________________
Other _______________________
(FORM 300)