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248-366-5055

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Please note: We cannot bind coverage from an email request. Coverage is bound after you receive a written email or telephone confirmation from an agency staff member.

Personal Information


Effective Date (yyyy-mm-dd):

Name: (First Middle Last)





Street:

City

State:

Zip Code:

Daytime Phone:

Email Address:

Driver's License Number

Choose one:	Please call me with quote premium. Please send quote via e-mail.

Referred By:

	*Current Coverage*

Company:

Expiration Date (yyyy-mm-dd):


Type of policy desired:

Amount of Insurance Desired

Homeowners only:
What is the value of your home?

Condo/Renters only:
What is the value of your personal property?

Liability Limit:

Medical Payments:

Valuation of Home:

Personal Property Valuation:

Deductible:

Property Information

What is the construction type of your home?

In what year was your home built?

In what County/Township are you located?

Distance to the nearest fire hydrant?

What kind of pets do you have?

Do you have a swimming pool?
Yes No

Do you have a trampoline?
Yes No

Do you use a wood burner?
Yes No

Smoke Detector(s) Installed
Home Security System Installed

Home Updates: Enter year updates were made. If year not known, enter "unknown":

Roof:

Plumbing:

Wiring:

Heating:

Optional Property Coverages

Earthquake Coverage Requested
Flood Coverage Requested
Sewer/Water Backup Coverage Requested

Property Floaters - Indicate limits below:

Antiques:

Furs:

Coins:

Jewelry:

Computers:

Stamps:

Fine Arts:

Tools:

Other Floater Coverage:

Limit of Insurance:

Previous Loss Information
Please describe any losses or claims filed on your Homeowners Insurance in the last 3 years:
Be sure to include the date of loss, type of loss and the amount of the claim.

Additional Comments
Please use the box below to enter any additional information you wish to include:

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© 2009 Jim Collier Insurance
1135 Round Lake Rd.
White Lake, Michigan 48386

Jim Collier, Oakland county Michigan Independent Insurance Agent --

MI Insurance Contact

248-366-5055

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