Home and Auto Insurance Quote

4501 24 Mile Rd. Ste C
Shelby Township, MI 48316

586-710-7613
www.miafsinsurance.com

How did you hear about us?

Please type in the name of who referred you

Name

First NameLast Name

Date of Birth

Date

Drivers License Number

Phone Number

E-mail

example@example.com

Second Named Insured

First NameLast Name

Date of Birth

Date

Drivers License Number

Phone Number

Second Named Insured E-mail

example@example.com

Property Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Is this also the Mailing Address?

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Do you own or rent

Home Billing

Style of Home

Year Purchased

Year Built

Home Sq. Ft.

Garage (# of Cars)

Enter 0 if no Garage...

Number of Bedrooms

Number of Total Baths

Roof Type

Age of Roof

Foundation

Is Basement Finished

Please Explain Foundation Type

Dog(s) in the home

Breed(s)

List all dogs and breeds

Pool?

Above Ground or Inground?

Slide

Diving Board

Is the yard Fenced?

Fireplace / Wood Burning Stove / Pellet Stove

Please Describe

Please list and provide approx month/year of update for each.

Updates to Electrical, Plumbing, or A/C?

Please list and provide approximate year of update for each.

Claims in last 5 years?

Claim type, year and amount paid (ie. water, wind)

Upload Current Home Declaration Pages

Browse Files

Home Declaration Pages