Name *

Address *

City *

State *

Zip Code *

Home Phone

Work Phone

Email Address

Website

County

Responding Fire Dept

Miles From Fire Dept

Is There a Fire Hydrant Within 1,000 feet? Yes No

Birthdate of Primary Member of Household

Birthdate of Spouse (if any)

Occupation & Employer

Spouse's Occupation and Employer

What Coverage Limit do you have or want on the dwelling?

Choose Desired Deductable 250 500 1,000

Choose Liability Limit 100,000 300,000 500,000 1,000,000

Guest Medical Payment Limit 1,000 5,000

Approx. Sq. Ft of House

Frame or Brick Frame Brick

If brick, what percentage is brick?

Year House Waws Built

Age of Roof (Enter Year)

Age of Furnace (Enter Year)

Age/Condition of Plumbing

Age/Condition of Wiring

Who is, or will be living in the house?

List all pets owned, if dogs, please list breed

Homeowners policies from most companies exclude damage from any type of water in the home including backup of water through sewer, sump pumps or drains. Some companies let you add additional coverage to add limited coverage for backup of sewer, sump pump or drains. Are you concerned about this? No, I don't Care
Yes, I want Coverage
Maybe, depends on the cost

Do you own, or plan on owning a satellite dish? Yes No

Do you own, or plan on owning a swimming pool? Yes No

Do you own, or plan on owning a trampoline? Yes No

Do you own, or plan on owning a hot tub? Yes No

Please describe any and all claims you have had in the last 5 years on a homeowners or renters policy--even if it was a different home. Include amount of claim and approx. date. If none, type none.

If you recently purchased the home, please enter the price paid and year purchased

If you are just now buying the home, what is the closing date?

Does ANYONE in the household smoke? Yes No

How many smoke detectors do you have?

Do you have at least one fire extinguisher? Yes No

Do you have deadbolt locks on ALL doors leading outside? Yes No

Do you have an alarm system? Yes No

If you answered yes to alarm system, please describe how it works and whether it makes noise, notifies a central station etc.

Do you have a wood burner? (Not a Fireplace) Yes No

Please list any recreational vehicles, sporting equipment, or watercraft

Do you have any high valued jewelry, art, collectible's, guns, computer equipment, etc? Please list items and their value

If you are a member of any group such as MEA, AARP, Mich. Assoc. of Community Bankers, Credit Union, etc?:

Your Current Insurance Agent

Current Insurance Company

Policy Number

Annual Premium you are paying currently

Expiration date of current policy

Is your current company canceling or non-renewing you? If so, Why?

What company currently insures your Autos?

Thank you for your request, we will get back to you shortly.