Mid Michigan Insurance Agency_01-0440-00

Name*

First NameLast Name

Spouse Name

First NameLast Name

Location Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mailing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

E-mail*

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Please fill out the questions below, or if you would prefer to receive a call back to provide your information skip to the bottom and click submit. An insurance professional will be in touch shortly.

Township

County

Type of home

If it's modular, is it:

Year home was built

Total square feet

Roof:

what year?

Electric:

what year?

Plumbing:

what year?

Furnace:

what year?

List all updates and additions and year completed

Number of stories

Type of basement

If it's a trailer, is it on a permanent foundation?

YesNo

List trailer make, model and serial number

Is the house?

Is the roof?

Current Insurance Company

Liability limits

300500

Current Deductible

What is the value of the dwelling

List any claims in the last 5 years

How many household members are there?

Household Members

Owner #1's Occupation

Owner #2's Occupation

Does anyone in the house smoke?

YesNo

Is there a trampoline?

YesNo

Is there a pool, pond, or hot tub?

YesNo

If yes, is it fenced?

YesNo

Any of the following windows?

BayBowPicture

Any of the following doors?

Sliding GlassFrench

Type of walls and ceilings (drywall, tongue and groove...)

Number of full bathrooms

Number of half bathrooms

Is there a garage?

Size of garage

Any other buildings on the property?

Are there smoke detectors?

YesNo

Is there a central alarm system?

YesNo

Is there a deck or patio?

YesNo

Are there skylights?

YesNo

Is there air-conditioning?

YesNo

Is there a wood-stove / corn burner?

YesNo

Is there a fireplace?

YesNo

If yes to fireplace:

ChimneyGas

List any pets or animals

List memberships to credit unions, alumni or other groups

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