*Name:    
*Address: 
*City:        *State: *Zip code: 
*Home phone number:    and/or   Work phone number:
Email address:          
Web Site Address:
County (not Country):    Responding Fire Dept:
Miles from Fire Dept:
Is there a fire hydrant within 1,000 feet Y or N?
Birthdate of primary member of household? Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ,

Birthdate of spouse if any? Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ,
Your occupation & employer:               
Your spouse's occupation & employer: 
   
What Coverage Limit do you have or want on the dwelling?:       

Choose desired deductible: 
$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 your house:
Frame or Brick?
If Brick, what percentage is brick?
Year your house was built:
Age of roof (Enter the Year):
Age of furnace (Enter the Year):
Age/Condition of plumbing (Enter latest update year & describe)
Age/Condition of wiring (Enter latest update year & describe)  
Who will be/is living in the house?  
List all pets owned or put "none". If dog(s), 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-don't care  Yes, I want coverage Maybe-depends on cost.

Do you own now, or do you plan to get a satellite dish?:     No    Yes
Do you own now, or do you plan to get a swimming pool? No   Yes
Do you own now, or do you plan to get trampoline?             No   Yes
Do you own now, or do you plan to get a hot tub?                No   Yes

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, then type in "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?:
How many smoke detectors do you have? :
Do you have at least one fire extinguisher?: 
Do you have deadbolt locks on ALL doors leading outside?
Do you have an alarm system?
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?:                     (fireplace is NOT a woodburner)
Do you have any recreational vehicles, sporting equipment, or watercraft?  Please list:

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, what?:

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?:  

Coverage Notes: In addition to the dwelling limit and liability limit, our quotes will typically include:

Other Structures at 10% of the dwelling limit

Personal Property at 70% of the dwelling limit

Loss of Use at 20% of the dwelling amount or one year

Personal Property Replacement Cost

Extra comments:

How did you find our site?
  Yahoo Other Search Engine Referral From a Friend/Relative Ad in Detroit News Ad in Wall St. Journal Ad in Lansing State Journal Ad in Jackson Cit. Pat Ad in Town Crier Radio Ad Television Ad Received Info In Mail

If "Other search engine" or just "Other", which search engine or where?

Thank you for completing our online quote form.
Please let us know how you would like us to send you the quote:
  Phone Call      Fax   Email  U.S. Mail

If you entered "phone call", what is the best time to call?

If you entered "Fax", what is your fax number: