Homeowner Insurance Quote Form
Great Lakes Independent
Please Select an Agent
*
Please Select
Dalton Kabold
Daniel Shubeck
Danielle Morrison
Greg McGinty
Griffin Sheposh
Jeff Maus
Jennifer Arnason
Jim Hutton
Larry McKheen
Linda Rose
Lonnie Allen
Rick Menary
Sandie Vermilya
Unsure, please pick an agent for me.
Your Name:
*
First Name
Last Name
Spouse Name (if applicable):
First Name
Last Name
Your DOB:
Spouse DOB (if applicable):
Property Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
At address 2 years or more?
Yes
No
Prior Address:
Mailing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
New Purchase?
Yes
No
Primary Residence?
Yes
No
Marital Status:
Single
Married
Home Phone:
-
Area Code
Phone Number
Cell Phone:
-
Area Code
Phone Number
Work Phone:
-
Area Code
Phone Number
Your Email:
*
Currently Insured?
Yes
No
How Long?
Any Claims?
Yes
No
Present Company:
Present Coverages (List Amounts):
Coverage A Dwelling:
Coverage B Other Structures:
Coverage C Personal Property:
Coverage D Liability:
Deductible:
Wind/Hail Deductible:
Bankruptcy or Foreclosure:
Yes
No
What year?
Year Built:
UPDATES:
Roof:
Heat:
Plumbing:
Electrical:
Construction Type:
Square Footage:
Roof Type:
Roof Shape:
Number of stories:
Number of bathrooms:
Garage?
None
Attached
Detached
If garage available, number of cars?
Foundation:
Slab
Crawlspace
Basement - fully finished
Basement - partially finished
Basement - not finished
Enclosed:
Yes
No
Alarm:
Yes
No
Property Market Value:
Heating/Cooling Type:
Within the City Limits?
Yes
No
Type of Road?
Paved
Dirt
Nearest Fire Department:
Distance:
Fire Hydrant Distance:
Pool?
Yes
No
Fenced?
Yes
No
Slide?
Yes
No
Diving Board?
Yes
No
Hot Tub?
Yes
No
Wood Stove?
Yes
No
Trampoline?
Yes
No
Dogs?
Yes
No
# of Dogs:
Breed:
Farm Animals?
Yes
No
Type:
Additional Coverage Options:
Jewelry
ID Theft
Cyber
Water Back Up
Service Line
Matching Siding
Upload Homeowners Declaration Sheet
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