Dwelling Fire Insurance Quote

Celebrating over 150 continuous years of service to
Marshall Michigan, and the State of Michigan

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Dwelling Fire Insurance Quote Form One Simple Form - takes only 2-3 Minutes! Your Personal Data:

Your Name:
Property Address:
City:
State:	Michigan!
Zip/Postal:
E-Mail (REQUIRED):
E-Mail (again for accuracy):
Phone:
Fax (optional):


Dwelling Information

Year Home Built:
Home Square footage:

Is this Builder's Risk? (new home constr.)	NO YES

Month/Year home to be complete:

Number of units:	1 family Duplex

Type foundation:	Slab Crawlspace over slab Pier & Post Other (list in remarks)

Type Construction:	Frame Brick/Veneer Stone Other (list in remarks)

Type Roof:	Shingle Wood Shake Tar/Gravel Spanish Tile Metal Other

Number of stories:	One 1.5 Two Three

Do you own animals or pets?	Yes No
If yes, list type/for dogs, list breed:

Are You Near Brush Area?	Yes No

# of feet to nearest fire hydrant:	# of miles to nearest fire station:

Currently Insured?	Yes No
Name of Carrier & how long insured?

Prior Claims?	Yes No
Describe claims in detail:

Rate Your Credit History and Past Insurance Payment History: (Some companies products are based on your credit and payment history.)	Excellent Fair Poor Horrible

Plumbing type:	Copper Galvanized Mixed (Copper/Galvanized)

Circuit Breakers or fuses?	Breakers Fuses

# Bedrooms:		# Bathrooms:

# Fireplaces:		# Chimneys:

Special features (i.e., deck, air conditioning, alarm systems, pool, etc.)

Coverages:

Dwelling Cov. $		Contents $
Liability Cov. $		Deductible $ ($250, $500, $1,000, etc.)

Comments/Remarks (describe any scheduled jewelry, in-home business, or other special coverages needed here):

Send my quotation via:		E-Mail Fax Regular Mail Call Me by Phone

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We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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Sullivan Insurance Agency, Inc.
140 W. Michigan Ave.
Marshall, MI 49068
Phone: 269-781-8909
Fax: 269-781-3535