Great Lakes Independent_11-0086-00

Auto & Home Insurance Quote Form

Great Lakes Independent
Please Select an Agent*
Contact Information:
Your Name:*

First NameLast Name
DOB:
Marital Status:

SingleMarried
If Married, Spouse Name:

First NameLast Name
Spouse DOB:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
At address 2 years or more?

YesNo
Prior Address:
Living Situation - Select One Option:

RentOwn HomeMobile HomeApartmentLive w/ ParentOther
Home Phone:

Area CodePhone Number
Cell Phone:

Area CodePhone Number
Work Phone:

Area CodePhone Number
Email:*
example@example.com
Occupation:
Total Number of Residents:
Auto Insurance Information:
Licensed Driver(s) at Address (after clicking 'Save Driver' you may add additional drivers):
Currently Insured?

YesNo
Company:
How Long:
Policy Expiration Date:
VEHICLE INFORMATION:
Any Additional Equipment or Features:

YesNo
Bodily Injury Limits:

100/300250/500500/5001000/1000
Under/Uninsured Motorists:
Roadside Assistance:
Rental:
Comprehensive Deductible:

$100$250$500$1000
Collision Deductible:

$100$250$500$1000
Personal Injury Protection (PIP) :

Unlimited$500,000$250,000$250,000 with excluded persons (list excluded persons below)$50,000 with MedicaidNo PIP with Medicare A and B
If applicable, list excluded persons from option 4 above:
TRAFFIC VIOLATIONS OR ACCIDENTS IN LAST 5 YRS:
Any Claims in Last 5 Yrs (Including COMP / PIP):

YesNo
Current Auto Premium:
Attach Currently Auto Policy (not required):

Browse Files

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Home Insurance Information:
Property Address (if different from previously requested address above):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
New Purchase?

YesNo
Primary Residence?

YesNo
Currently Insured?

YesNo
If yes, how long?
Any Claims?

YesNo
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:

YesNo
What Year?
Year Built?
UPDATES:
Roof:
Heat:
Plumbing:
Electrical:
Construction Type:
Square Footage:
Roof Type:
Roof Shape:
Number of stories:
Number of bathrooms:
Garage?

NoneAttachedDetached
If garage available, number of cars?
Foundation:

SlabCrawlspaceBasement - fully finishedBasement - partially finishedBasement - not finished
Enclosed?

YesNo
Alarm?

YesNo
Property Market Value:
Heating/Cooling Type:
Within the City Limits?

YesNo
Type of Road?

PavedDirt
Nearest Fire Department:
Distance:
Fire Hydrant Distance:
Pool?

YesNo
Fenced?

YesNo
Slide?

YesNo
Diving Board?

YesNo
Hot Tub?

YesNo
Wood Stove?

YesNo
Trampoline?

YesNo
Dogs?

YesNo
# of Dogs:
Breed:
Farm Animals?

YesNo
Type of Animals:
Additional Coverage Options:

JewelryID TheftCyberWater Back UpService LineMatching Siding
Upload Homeowners Declaration Sheet:

Browse Files

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Auto & Home Insurance Quote Form