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Order Form

Contact Form
Order Form
Use this order form to send orders to AIS. 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:
Property #1
Insured Name:
Policy Number:
Address:
City: State: Zip:
* Insured Phone:
* Coverage A:
*(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:
* Insured Phone:
* Coverage A:
*(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:
* Insured Phone:
* Coverage A:
*(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.

 


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