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Order Form

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Order Form
Use this order form to send orders to AIS. Please include all required contact information (fields in red bold below); you will not be able to submit your order without all required fields. You can enter three properties per page. Click "ENTER" at the bottom to submit your order. If you have any questions, please call AIS at (815) 744-7307 or contact us online.
* Agent:
* Contact:
* Phone: Fax:
* E-mail:

* Please Enter Code As Shown:
  * Required
Property #1
Insured Name:
Policy Number:
Address:
City: State: Zip:
1 Insured Phone:
1 Coverage A:
1(Optional); **(needed if appointment is necessary)
Supplement: Heating & Electrical Inspection
(Includes photo of power panel)
Wood Burning Stove
(Includes photo of stove)

Details and special requests:
Property #2
Insured Name:
Policy Number:
Address:
City: State: Zip:
1 Insured Phone:
1 Coverage A:
1(Optional); **(needed if appointment is necessary)
Supplement: Heating & Electrical Inspection
(Includes photo of power panel)
Wood Burning Stove
(Includes photo of stove)

Details and special requests:
Property #3
Insured Name:
Policy Number:
Address:
City: State: Zip:
1 Insured Phone:
1 Coverage A:
1(Optional); **(needed if appointment is necessary)
Supplement: Heating & Electrical Inspection
(Includes photo of power panel)
Wood Burning Stove
(Includes photo of stove)

Details and special requests:

All completed inspections will be emailed in a timely manner.
Please make sure all required contact information is filled out.

 


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