Home and Auto Insurance Quote

MIAFS Macomb
Michigan Insurance and Financial Services

4501 24 Mile Rd. Ste C

Shelby Township, MI 48316

586-913-8989

www.miafsmacomb.com
How did you hear about us?
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Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Drivers License Number*
Phone Number*
E-mail*
example@example.com
Second Named Insured

First NameLast Name
Date of Birth

MonthDayYear
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?*

YesNo
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Do you own or rent*

OwnRent
Home Billing*

EscrowedPaid in FullPaid Monthly
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*

BasementCrawl SpaceSlabOther
Is Basement Finished

YesNo
Please Explain Foundation Type
Dog(s) in the home*

YesNo
Breed(s)
List all dogs and breeds
Pool?*

YesNo
Above Ground or Inground?

AboveInground
Slide

YesNo
Diving Board

YesNo
Is the yard Fenced?

YesNo
Fireplace / Wood Burning Stove / Pellet Stove*

YesNo
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*

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