Effective Date:
Your Name:
Your Mailing Address: Street

City & State                                                     Zip
  
E-mail Address:
Daytime Phone #:
Choose One: Please call me with quote premium.
Please send quote via e-mail.
Current coverage: Company:                                       Expiration Date:
 
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:


Wiring:
 Plumbing:


Heating:
Optional Property Coverages:
Earthquake Coverage Requested
Flood Coverage Requested
Sewer/Water Backup Coverage Requested
Property Floaters - Indicate limits below:
Antiques:


Coins:


Computers:


Fine Arts:
 Furs:


Jewelry:


Stamps:


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:

Date of loss:               Type of loss:                                                Amount of claim:
Additional Comments
Please use the box below to enter any additional information you wish to include:
        
myagent@veenstrainsurance.com
Local: (248)553-3000 . Toll free: (800)445-6554 . Fax: (248) 553-8482
31700 W. 12 Mile Road . Suite 200 . Farmington Hills . Michigan . 48334-4461