Coverage Deductible Total
Building Amount of Rate Annual Premium
Insurance Premium Reduction
Basic _________ ____ ________ ___________ $________
Additional _________ ____ ________ ___________ $________
Coverage Deductible
Contents Amount of Rate Annual Premium
Insurance Premium Reduction
Basic _________ ____ ________ ___________ $________
Additional _________ ____ ________ ___________ $_________
Subtotal $________
CRS Premium Discount _______%(Only Lincoln & Fremont) $________
Subtotal (After CRS Credits) $________
ICC Premium $________
Probation Surcharge (Only if community is on probation) $________
Federal Policy Fee $30.00
Grand Total $________