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Home Owner Insurance Quote

Please fill out the information below to the best of your knowledge. Upon receiving your quote request we will review the information provided and contact you. The more complete and honest your quote request, the quicker we can provide you with an accurate quote.

Personal Information

Applicant 1
  First Name:
  Middle Initial:
  Last Name:
  Address:
  City:   State:   Zip:
  Date of Birth:
  Employer:
Applicant 2
  First Name:
  Middle Initial:
  Last Name:
  Address:
  City:   State:   Zip:
  Date of Birth:
  Employer:
Relationship Between Applicant 1 and 2:
Contact Phone:
Email Address:
How Would You Prefer to be Contacted?
How Did You Hear About Us?

Policy Information

Dwelling Coverage:
Liability Limit:
Deductible:
Current Insurance Company:
Current Coverage Effective Dates From: to:

General Information

Year Built:   Square Footage:
Stories:   Basement Completion:
Construction Type:   Siding Type:
Garage:   Garage Size:
Type of Flooring:   Feet to Nearest Hydrant:
Miles to Fire Department:   Responding Fire Department:

Safety Features of Your Home

Does your home have:
(Check all that apply)		  Smoke Detectors    Fire Extinguisher    Deadbolt Locks
 Burglar System    Motion Sensing Lights    
Are You a Non-Smoker?Yes No

Year of Renovation

Roof:     Electrical:
Heating:     Plumbing:

Prior Claims

Claim 1
    Date:
    Cause:
    Amount Paid Out:
Claim 2
    Date:
    Cause:
    Amount Paid Out:
Claim 3
    Date:
    Cause:
    Amount Paid Out:

Do You Have...

(Check all that apply)    Wood Stove    Pets    Jewelry
     Boats/RV    Trampoline   Fireplace: 
     Pool   If You Have a Pool, Is it Fenced? Yes No

Additional Information

Please give any additional comments you feel appropriate for this quotation. If you have additional information that did not fit in the fields above, please enter them here.

By clicking the submit button I am acknowledging that I have read the Terms & Conditions and that I agree to be bound by those Terms & Conditions.

 

 
 

Worgess Insurance Agency   Battle Creek Office:  55 North McCamly Street   Battle Creek, MI 49017    Contact     P: 269-965-3221   F: 269-965-8853 
Kalamazoo Office:   350 East Michigan Avenue  Kalamazoo, MI 49007    Contact     P: 269-488-3221   F: 269-965-8853   Terms and Conditions