About Us   |   Home Owners   |   Business Insurance   |   Auto & Recreational   |   Life Insurance   |   Contact Us

Personal Property Quote Questionaire

Please complete the form below and submit through our Secure Server
 
Customer Information
Name  
Home Address  
   
City   State Zip
If other location, please specify  
Date of Birth (MM/DD/YYYY)  
Social Security Number  
Phone Number  
Cellphone Number  
Work Number  
Fax Number  
Your Email Address *  
Occupation  
Employer  
     
Property Information
Year Built  
Heat Type  
if Oil heat, where is tank?  
# of Families  
Skateboard Ramp  
Trampoline  
Basement  
Square Footage  
# of Stories  
# of Fireplaces  
# of Garages  
Frame or Masonry  
Distance to Fire Hydrant  
Distance to Fire Department  
Renovations/Updates
(check all that apply)
  Electrical    Plumbing    Heating    Roof
Burglar Alarm    Smoke Detectors    Fenced Yard
Swimming Pool  
List Animals (if any)  
     
Coverage & Loss
Dwelling Coverage Amount   $
Liability Coverage Amount   $
     
Please indicate any losses/claims
  Date   Description   Claim Amount Paid
     
     
     
     
     
Mortgagee Information
Name  
Address  
Loan #  
Phone Number  
     


Copyright © The Michaels Agency, Inc. All rights reserved.