Tell us about you!
Contact info
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Discounts
Help us save you money!
Are you current/retired military (including widowed spouses) or a member of any of these eligible professional associations?
• Academy of Nutrition and Dietetics
• American Academy of Pediatrics
• American Association of Diabetes Educators
• American Association of Engineering
Societies (AAES)
• American Association of Medical Assistants
• American Association of Nurse Practitioners
• American Association of Orthodontists
• American Association for Respiratory Care
• American Association of School
Administration (AASA)
• American Bar Association
• American Dental Association
• American Engineering Association (AEA)
• American Foundry Society
• American Health Information
Management Association
• American Heart Association
• American Institute for Certified Public
Accountants (AICPA)
• American Institute of Architects
• American Medical Association
• American Nurses Association – MI
• American Pharmacists Association
• American Physical Therapy Association
• American Public Health Association
• American Society of Anesthesiologists
• American Society of Consultant
Pharmacists (ASCP)
• American Welding Society
• Association of Diabetes Care &
Education Specialist
• Association of Specialty Cut Flower Growers
• Association for Supply Chain Management
(ASCM or APICS**)
• Business Network International (BNI)
• Current/Retired Military†
• Dairy Farmers of America
• Detroit Police Officers Association
• Greenstone Members and Employees
• Hagerty Drivers Club Members, Employees
and Insureds
• Homeland Security Employees
• Institute of Electrical and Electronics
Engineers (IEEE)
• Institute of Management Accountants (IMA)
• International Association of Fire Fighters
• Irrigation Association
• Metro Detroit Flower Growers Association
• Michigan Academy of Family Physicians
• Michigan Academy of Nutrition and Dietetics
• Michigan AFL-CIO Affiliated Unions‡
• Michigan Agri-Business Association (MABA)
• Michigan Agricultural Cooperative
Marketing Association
• Michigan Agriculture Environmental
Assurance Program
• Michigan Air Conditioning Contractors
• Michigan Allied Poultry Industries
• Michigan Association of Ambulance Services
• Michigan Association of Beauty Professionals
(MI Beauty Pros)
• Michigan Association of Certified Public
Accountants (MICPA)
• Michigan Association of Chiefs of Police
• Michigan Association of Chiropractors
• Michigan Association of Convenience Stores
• Michigan Association of Fire Fighters
• Michigan Association for Justice
• Michigan Association of Police
• Michigan Association of Public Health
• Michigan Association of School Boards
• Michigan Association of Superintendents &
Administrators
• Michigan Association of Timbermen
Self-insurers’ Fund
• Michigan Bankers Association
• Michigan Bed & Breakfast Association
• Michigan Blueberry Commission
• Michigan Cattlemen’s Association
• Michigan Corn Growers’ Association
• Michigan Council of Nurse Practitioners
• Michigan Dental Association
• Michigan Dental Hygienists’ Association
• Michigan Education Association (MEA)
• Michigan Farmers Market Association (MIFMA)
• Michigan Floral Association
• Michigan Funeral Directors Association
• Michigan Green Industry Association
• Michigan Library Association
• Michigan Manufacturers Association
• Michigan Meat Association
• Michigan Medical Group
Management Association
• Michigan Mechanical Contractors Association
• Michigan Milk Producers Association
• Michigan Mortgage Lenders Association
• Michigan Nursery and Landscape Association
• Michigan Nurses Association
• Michigan Osteopathic Association
• Michigan Petroleum Association
• Michigan Pharmacists Association
• Michigan Physical Therapy Association
• Michigan Physicians Society
• Michigan Plumbing & Mechanical
Contractors Association
• Michigan Professional Fire Fighters Union
• Michigan Propane Gas Association
• Michigan Podiatric Medical Association
• Michigan Pork Producers Association
• Michigan Pupil Accounting and Attendance
Association (MPAAA)
• Michigan Realtors Association
• Michigan Restaurant & Lodging Association
• Michigan Retailers Association
• Michigan School Business Officials
• Michigan Sheriffs’ Association (MSA)
• Michigan Society for Respiratory Care
• Michigan Society of Anesthesiologists
• Michigan Society of Medical Assistants
• Michigan Society of Professional
Engineers (MSPE)
• Michigan State Association of Letter Carriers
• Michigan State Medical Society
• Michigan State Police Command
Officers Association
• Michigan State Police Troopers Association
• Michigan Tactical Officers Association (MTOA)
• Michigan Vegetable Council
• Michigan Veterinary Medical Association
• Million Dollar Round Table
• Mortgage Bankers Association
• National Association of Elementary School
Principals (NAESP)
• National Association of Fundraising Professionals
• National Association of Insurance and Financial
Advisors (NAIFA)
• National Association of Letter Carriers
• National Association of Neonatal Nurses
• National Association of Realtors & Affiliates
• National Association of Social Workers
• National Association of Tax Professionals
• National Bankers Association
• National Board for Respiratory Care
• National Education Association (NEA)
• National Electrical Contractors Association
Michigan Chapter
• National Federation of Independent Businesses
• National Rural Letter Carriers Association
• National Society of Accountants
• National Society of Professional Engineers
• Order of the Engineer
• Police Officers Association of Michigan
• Plumbing-Heating-Cooling
Contractors Association
• Professional Golf Association
• Project Management Institute
• Retired Detroit Police & Fire Fighters Association
• Society of Automotive Engineers (SAE)
• Society of Chartered Property and Casualty
Underwriters (CPCU Society)
• Society of Manufacturing Engineers
• State Bar of Michigan
• State of Michigan employees
• Sunrise Networking Group
• The Engineering Society of Detroit (ESD)
• The Property Management Association
of Michigan
• Young Professionals Network
Discount Question
Are you a part of any of these eligible civic associations?
• American Legion
• American Woodcock Society
• Antique Automobile Club of America (AACA)
• Basketball Coaches Association of Michigan
• Board or Committee Members of
Non-Profit Organizations
• Boaters Association of Michigan
• Boy Scouts of America
• Chamber of Commerce
• Detroit Economic Club
• Ducks Unlimited
• Fraternal Order of Eagles
• Girl Scouts of the U.S.A.
• Home Builders Association of Michigan
• Kiwanis
• Knights of Columbus
• Lions Club
• Members of the Farm Bureau Credit Union
• Michigan Boating Industries Association
• Michigan Charter Boat Association
• Michigan Elks Association
• Michigan Future Farmers of America Association
(FFA) & FFA Alumni
• Michigan Grand Lodge of Free and
Accepted Masons
• Michigan High School Athletic Association
• Michigan Lakes and Streams Association &
Member Associations
• Michigan Longbow Association
• Michigan Pheasants Forever
• Michigan Snowmobile & ORV Association
• Michigan Taxidermist Association
• Michigan United Conservation Clubs & Affiliates
• National Ski Patrol
• National Wild Turkey Federation
• Private or semi-private country
club membership
• Property/Condo Owners Association
• Quality Deer Management Association
• Rocky Mountain Elk Foundation
• Rotary Club
• Ruffed Grouse Society
• Safari Club International Foundation
• Semi-private and Private Yacht Clubs/
Country Clubs
• UP Whitetails Association
• Veterans of Foreign Wars (VFW)
Discount Question
Are you a university alumni member? Which university?
Would you be interested in our telematics program, which tracks your good driving and mileage to give you up to 40% discount!?
Yes
No
Are you currently with any of these companies, or have you been quoted by them recently? If so, and you provide us your declaration pages, we might have a discount for you!
Citizens/Hanover
Auto Owners/Home Owners
Frankenmuth
Pioneer
Hastings
Fremont
Would you be interested in paying in full for 6 months or 1 year, to DRASTICALLY save money?! (Many of our customers pay with a card, get points/miles/cash back and vastly increase their savings and benefits!)
Yes
No
Show me both monthly and full pay options
Tell us what to insure!
Who and what can we protect for you!?
Drivers (Full Name & Date of Birth)
Tell us about each drivers commutes. (work/school?) (How far one way?)
Anyone have tickets or accidents in the last 36 months? (Describe)
Vehicles (Year, Make, Model & Loan/Lease/Owned)
Home/Condo/Apartment? (Own, Mortgage, Rent?)
Do you currently waive medical coverage on your auto insurance, using your health insurance provider instead?
Yes
No
I don't know
Would you like an umbrella quoted as well?
Yes
No
I don't know
Do you own a business? If so, would you like us to quote that to greatly increase your savings on BOTH your personal AND business policies?!
Yes
No
I do not own a business
Submit
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