Van Gordon Insurance Agency - Application Form

HOMEOWNERS INSURANCE

APPLICATION FORM
Is this a Homeowners policy or a Landlord policy?*

HomeownersLandlord
Marital Status*

SingleMarried
Secondary Named Insured*

First NameLast Name
Phone Number*
Date of Birth*

MonthDayYear
Secondary Named Insured's Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Property Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How many stories? *
How many bathrooms?*
How many bedroom?*
Year built *
Square footage of house*
Do you have a mortgage?*

NoYesUnknown
Do you have a basement?*

NoYes, unfinishedYes, finishedMichigan basementOther
Any outbuildings?*

NoAttached garageDetached garagePole barnMultiple outbuildingsOther
Roof Age*

Less than 5 yearsLess than 10 yearsLess than 15 yearsLess than 20 yearsGreater than 20 yearsUnknown
Any additional Information?
Please upload any documents here

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AUTO INSURANCE

APPLICATION FORM
Is this Auto Insurance quote for a Business?

YesNo
Name of Business*
Business Address*

Street Address

Street Address Line 2

CityState

Zip Code
Nature of Business*
List of Drivers*
List of Vehicles*
Desired Property Damage Coverage Limit*

25,00030,00050,000100,000250,000500,000
Desired Bodily Injury Coverage Limit*

30,000/60,00050,000/100,000100,000/300,000250,000/500,000500,000/500,000Other
Desired Uninsured Motorists*

30,000/60,00050,000/100,000100,000/300,000250,000/500,000Other
Comprehensive coverage*

YesNo
Comprehensive Deductible*
Collision coverage*

YesNo
Collision Deductible*
We will need the following documents
1. Valid and current Driver Licenses
2. Valid Registrations
3. Photos of the vehicles: 
 - Front, rear, left and right side (The photos will need to show the entire vehicles)

If our office needs anything else, we will reach out to you.
Take Photo
Please upload any documents here

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COMMERCIAL INSURANCE

APPLICATION FORM
Company Name*
Doing Business As (DBA)
Legal Entity*

NonprofitCorporationPartnershipIndividualLLCOther
Is your Mailing Address the same as your Business Address*

NoYes
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance coverage requested*

Business Owner Policy (BOP)Commercial AutoGeneral LiabilityProfessional LiabiltyWorkers' compensationOther
Year Business Established*
FEIN number*
Gross Annual Revenue ($)*
Total Estimated Payroll ($)*
Number of Full-time employees*
Number of Part-time employees*
Current Insurance Carrier
Current Policy Expiry Date

MonthDayYear
Describe Professional Services offered?*
Do you have any information you would like to upload? Example are: Rent-roll if you are an owner of a building, Loss Run Report (Can be requested from your current Agent), and current insurance declaration pages etc. (You can always provide us later if the documents are not available at the moment)

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PROPERTY DETAILS

(Optional)
Year Built of the Property(If known)
Building or Occupied square feet
Building Property Value ($) if Desired
Personal Property Value ($)
LIFE INSURANCE

APPLICATION FORM
SSN*
What is your Alien Registration Number?
Alien Registration expiry date

MonthDayYear
Life Term*

10 year term15 year term20 year term30 year term
Permanent product*

Index Universal Life VULVariable Universal LifeVUL with Long Term CareAnnuity
Expected face amount*

$100,000$200,000$500,000$1,000,000$2,000,000Other
TRAVEL INSURANCE

APPLICATION FORM
When does your trip start?*

MonthDayYear
Date
When does it end?*

MonthDayYear
Date
Which country do you stay the longest in this trip? (Example: if you stay 7 days in Japan and 3 days in Korea, pick Japan)*
Do you have co-travelers?*

NoYes
Please provide your co-traveler's information*

Authorization to Release Information
We collect your insurance information electronically to verify coverage, process claims, and ensure accurate billing for services rendered. This enables efficient coordination with your insurance provider and helps streamline your service experience.

By clicking “Submit,” you acknowledge that:
- You have read and understood this disclosure
- You consent to the electronic collection and use of your insurance information
- Your submission has the same legal effect as a signed paper form
Should be Empty:

Insurance Application Form

HOMEOWNERS INSURANCE

AUTO INSURANCE

COMMERCIAL INSURANCE

PROPERTY DETAILS

LIFE INSURANCE

TRAVEL INSURANCE

Authorization to Release Information