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
 
City
 
State   Zip  
 
Phone (Home) (Work)
 
E-Mail   SS #
 
Currently Insured
 
Company   Expiration


VEHICLE INFORMATION
 
Car #1   Year   Make   Model
 
Vin   2/4 Door
 
Work/School Miles   Airbags   ABS
 
Alarm System

 
Car #2   Year   Make   Model
 
Vin   2/4 Door
 
Work/School Miles   Airbags   ABS
 
Alarm System


COVERAGE INFORMATION
 
Liability   Full Coverage
 
Health Insurance Coverage


DEDUCTABLES & OTHER COVERAGE INFORMATION
 
Car #1   Comp   Coll   RS   Rental
 
Car #2   Comp   Coll   RS   Rental


DRIVER INFORMATION
 
Driver #1   Name   DOB
 
Marital Status   Violations
 
Driver #2   Name   DOB
 
Marital Status   Violations


OTHER INFORMATION
 
Any claims in the last 5 years
 
Own/Rent Home   Group Member
 
Children in Household   Ages
 
Any other licensed drivers in household
 
How did you happen to call us


 

 
Homeowners Insurance Quote Form
 
 
Today's Date
 
Full Name
 
Address
 
City
 
State   Zip  
 
Phone (Home) (Work)
 
E-Mail   SS #


CURRENT HOME INSURANCE INFORMATION
 
Current Carrier   Expiration Date
 
Current Coverage Amount   Deductible
 
If new home purchase-purchase price
Closing Date


HOME INFORMATION
 
Year Built   Exterior Material   Sq Ft
 
# of Stories
 
Updates-Roof   Electric   Heat   Plumbing
 
Foundation type (basement, crawlspace)
 
If basement, percentage finished
 
Garage - Attached - Detached - None
 
Porches, Decks, Balconies   Sq Feet
 
# of baths - Full   Half   3/4
 
Heat Type (gas, electric, oil, other)   Central Air
 
Fireplace   Wood Stove
 
Pool or Hot-tub   If yes - Fenced & locked
 
Trampoline   If yes - Netted & fenced
 
Smoke Det   Deadbolts   Fire Extinguishers
Central Alarm System
 
Ft to Fire Hydrant   Miles to Fire Department
 
Responding Fire Department


OTHER INFORMATION
 
Business on premises   Claim last 3 years
 
How long at address
 
Any Pets   Type Dog
 
Any Livestock   Type   How many
 
Any scheduled items on current policy
 
Do you own a golfcart, ATV, snowmobile or boat
 
Group Member
 
How did you happen to call us