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Customer Details:
Primary Contact (Driver #1)
*
Prefix
First Name
Middle Name
Last Name
Suffix
Date of birth?
*
MM/DD/YYYY
Driver's License#
*
Driver #2
Prefix
First Name
Middle Name
Last Name
Suffix
Date of birth?
MM/DD/YYYY
Driver's License#
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you Own or Rent at this address?
Own
Rent
Phone Number
*
-
Area Code
Phone Number
E-mail
Vehicle Info
How many vehicles do you own?
If there are more than two vehicles in the household, we will contact you to gather the additional information.
Vehicle#1: Make/Model/Year/VIN
*
Vehicle#2: Make/Model/Year/VIN
Do you have a car insurance?
*
Yes
No
Your Insurance Company/Policy Number/Expiration Date
Monthly Payment or 6-month Premium
Vehicle #1: Comprehensive Deductible
Vehicle #1: Collision Deductible
Vehicle #2: Comprehensive Deductible
Vehicle #2: Collision Deductible
Auto/Home Discount(s)
Answer questions below for available discounts
Do you have Life Insurance?
Yes, I have a whole life policy
Yes, I have a term policy
No, but I would like to learn more.
Are you an alum of a Michigan college/university?
*
No
None Below
Adrian College
Albion College
Alma College
Aquinas College
Baker College
Calvin University
CMU
Davenport University
EMU
Ferris State University
Grand Valley State University
Hillsdale College
Hope College
ITT Tech
Jackson College
Kalamazoo College
Kellogg Community College
Kettering University
Lake Superior State University
Lansing Community College
Lawrence Technological University
Macomb Community College
Madonna University
Michigan State University
Michigan Technological University
Mott Community College
Muskegon Community College
Northwood University
Oakland Community College
Oakland University
Olivet College
Rochester College
Saginaw Valley State University
Schoolcraft College
Siena Heights University
Spring Arbor University
University of Detroit Mercy
University of Michigan
University of Phoenix
Washtenaw Community College
Wayne County Community College
Wayne State University
Western Michigan University
Professional Association
*
American Association of Engineering Societies
American Association for Marriage and Family Therapy
American Association of Nurse Anesthetists
American Association of School Administrators
American Bar Association
Accreditation Board for Engineering and Technology
American Board of Funeral Service Education
American Dietetic Association
American Osteopathic Association
American Veterinary Medical Association
Accreditation Council for Pharmacy Education
American Dental Association
American Institute of Certified Public Accountants
American Occupational Therapy Association
American Optometric Association
American Physical Therapy Association
American Psychological Association
Commission on Collegiate Nursing Education
Council on Education for Public Health
Current/Retired Military
Higher Learning Commission
IEEE
Irrigation Association
Michigan Agri-Business Association
Michigan Air Conditioning Contractors Association
Michigan Association of Ambulance Services
Michigan Association of Fire Fighters
Michigan Association of Police
Michigan Farmers Market Association
Michigan Plumbing & Mechanical Contractors Association
Michigan Realtors®
Michigan Restaurant & Lodging Association
Michigan Sheriffs' Association
National Council for Accreditation of Teacher Education
National Association of Letter Carriers
Other
Civic Association
*
American Legion
Antique Automobile Club of America
Boaters Association
Chamber of Commerce
Country Club Membership
Detroit Athletic Club
Duck Unlimited
Economic Club of Detroit
Elks Association
Farm Bureau Credit Union
Farm Bureau Family of Business
FFA
Home Builders Association
Homeowners/Condo Association
Kiwanis Club
Rotary Club
Pheasants Forever
Other
Best time to connect?
*
Mornings
Afternoons
Evenings
Weekends
How did you hear about us?
*
Brochure
Friend
Social Media
Other
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