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Home Owner 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

First Name: Last Name:
Day Phone: Evening Phone:
Email Address:
How would you prefer to be contacted?
How did you hear about us?
Address: State:
City: Zip:
Date of Birth: Employer

Policy Information

Amount of Coverage:
Liability:
Deductible:

General Information

Construction Type:
Responding fire department:
Miles to fire department?:
Feet to nearest hydrant?:
Basement Completion:
Year Built:
Stories:
 

Safety Features of Your Home

 
Does your home have:
(Select all that apply)
Smoke Detectors :
Fire Extinguisher:
 
   
Deadbolt Locks :
Burglar System:
 
 
Are you a non-smoker?
 

 

Year of Renovation

 
Roof:
Electrical:
 
Heating:
Plumbing:

Prior Claims

Do You Have...

Wood Stove
Pets
  
Jewelry
Boats/RV
  
Trampoline/Pool
      

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