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Home/Renter Insurance Quote Request
QUOTE FORMS
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CLAIMS
Claims Information

Please complete this form as completely and accurately as possible and submit it to us when you are finished. If you wish, you may also print out the form and fax it to us (734•662•5379) or call our office with this information.

Note that we cannot provide coverage until a policy or binder has been issued by the insurance company. As part of our quoting process, we may need to verify some information such as credit history, prior insurance history, and financial stability information.

Contact Information
Name:
Street address:
City:
State:
Zip code:
County:
Phone (home):
Phone (work):
Fax:
Email address:
Current Policy Information

Current insurance policy:
Policy expiration date:
Home value to be covered:
OR renter's contents:
Deductible: $100 $250 $500 Other
Liability coverage: $100,000 $300,000 Other

Current annual premium:
Number of claims in last 3 Years:
Property Information
Is location same as above?
 No Yes

If No, please complete location information:

Address:

City: State: Zip:

Ownership: Rent Own
Property is a: Home Condominium Townhouse Apartment

If condominium, how many units in the building?

How many years at present address? Year home was built:

Age of:

Roof: Heating system: Wiring: Plumbing:

Fire department name:
Miles from dwelling:
Nearest fire hydrant (in feet):
Structure Information

Type:





Sq. ft. (excluding basement and garage):


Construction:






Foundation:


Roof:





Garage:
Garage is: Attached Detached Basement Built-in Carport None

Features

Bathrooms:
# of Full:
# of half:

Deck/Porch/Patio:
Deck sq. ft.:
Porch sq. ft.:
Screened patio sq. ft.:

Trampoline:
Yes No

Basement:




Heating System:






Pets:
# of pets:
Claims? Yes No
If Yes, how many:

Fireplaces:
# of Fireplaces:
# of Chimneys:

Wood burning stove?
Yes No

Swimming Pool:





Scheduled Property:
Personal:
Computer:
Office Equip:

Security Systems
Dead Bolts:
Yes No

Smoke Detectors:
Yes No

 Extinguishers:
Yes No
Security Alarm:


Fire Alarm:

Additional Considerations/Requests
Please provide any additional comments you feel appropriate for this quote:

 

 

 

 

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