1355 East Napier
Benton Harbor,
Michigan 49022
· Online Auto and Home Insurance Quote Forms ·
 
All fields must be filled out to receive a return quote. If you prefer to print a form and send/deliver it to our office, please click the appropriate link below.
 
* Entering your social security number is optional. However, providing this information will help to ensure the lowest and most accurate quote, potentially saving even more money. By including it, your credit is not altered in any way.
 
These forms are for quoting purposes only. It is not a binder of insurance and is subject to the terms and limitations of the issuing company.
 
 
Auto Insurance Quote Form
 
 
Today's Date   Full Name
 
Address
 
Phone (Home) (Work)
 
Date of birth   * Social Security #
 
Miles one way to work
 
List violations/accidents/insurance claims in the last 3-5 years
 
Prior Insurance - Yes No Expiration date
 
Marital Status - Married Single
 
Spouses Name
 
Spouses DOB Miles one way to work
 
List spouses violations/accidents/insurance claims in the last 3-5 years
 
Children - Yes No Number of children
 
Age of each child
 
Any other licensed drivers in the household - Yes No
 
Vehicle Year Make Model
 
VIN #
 
2 or 4 door - 2 4   Type of vehicle - Car Pickup Van
 
Liability/PLPD or Full Coverage - Yes No
 
Deductibles Comp   Collison
 
Do you own or rent your home - Own Rent
 
Member of any group/affiliations:
 
Do you have health insurance that pays primary for medical bills in the event of an auto accident - Yes No
 
 
Homeowners Insurance Quote Form
 
 
Full Name
 
Address
 
DOB   * Social Security #
 
Current Carrier
 
Renewal Date
 
Current Coverage Amount
 
Deductible
 
Year Built   Exterior material
 
Square footage   # of stories
 
Updates - Roof   Electric   Heating   Plumbing
 
Foundation type (basement, crawlspace)
 
If basement, percentage finished
 
Garage - Attached   Detached   None
 
Any other out buildings
 
Porches, Decks, Balconies square footage
 
# of baths - Full   Half
 
Furnace - Gas   Electric   Oil
 
Central air - Yes No
 
Fireplace - Yes No   Woodstove - Yes No
 
Pool or hottub - Yes   No
 
If yes, yard fenced and locked - Yes   No
 
Any pets - Yes   No
 
Business on premises - Yes   No
 
List any claims in last 3 years
 
Any scheduled items on policy
 
Belong to any organizations