Sam Heron Lapeer Michigan Insurance Life Home Auto

Home Owners Insurance Quote request

Your Name:
Phone:
Fax:
E-mail:
Property Address:
City:
State:
Zip:

Year Built:
Owner's SS Number:
Owner's self credit rating:
Are you a smoker:
Square footage of house:
Do you belong to any groups? (Ex. AARP, Credit Union, Sam's Club)
Birth Date:
Please complete the following about the property
Township of Servicing Fire Department
Is property within 5 miles of the fire department?	Yes No
Are exterior walls 75% or more brick?	Yes No
Do you have a wood stove?	Yes No
Do you have a smoke alarm?	Yes No
Do you have a security alarm?	Yes No
External Siding:
Garage:
Number of cars:
Basement:
Enclosed porches:	Yes No
Square feet:
Decks:	Yes No
Square feet:

Coverage Desired
Dwelling Coverage
Loss of Use
Liability:
Deductible:
Additional Comments:
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