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

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Homeowners Insurance Quotation Form One Simple Form - takes only 2-3 Minutes! Your Personal Data:

Your Name:
Address:
Property Address:
City:
Township:
State:
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
Date of Birth:

Are you currently Insured? If so with whom?
Expiration Date:
Are there any smokers?	YesNO

Dwelling Information

Year Home Built:
Living area Sq. footage:

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

Month/Year home to be complete:

Number of units:	1 family Duplex Multiple Units

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

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

Type Roof: Year of Update:	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:
Number of Alarms?

Prior Claims?	Yes No
Describe claims in detail:

Plumbing type: Year updated:	Copper Galvanized Mixed (Copper/Galvanized)
Electrical: Year updated	Breakers Fuses
Furnace Year updated
A/C Yes`NO`
Do you have a woodstove?YesNO

# Bedrooms:
# Bathrooms:
# Fireplaces:

# Chimneys:

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

Coverage's:

Dwelling Cov. $

Contents $

Liability Cov. $

Deductible $
($250, $500, $1,000, etc.)

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

Send my quotation via: E-Mail Fax
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Sullivan Insurance Agency, Inc.
140 W. Michigan Ave.
Marshall, MI 49068
Phone: 269-781-8909
Fax: 269-781-3535