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Aviza Agency – Coldwater, MI
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Kirgis Agency – Ionia, MI
- Auto Quote
- Homeowners Quote
Kujala Agency – Highland, MI
- Auto Quote
- Homeowners Quote
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Homeowners Quote Highland

Customer Info:

Name:*

First

Last

Phone:

Area Code

-

Phone Number

E-mail:*

Address:*

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

1/3

Year Built:

Total Square Footage:

Substructure:

Year roof last replaced:

If you selected Basement is it:

Amount of coverage:

Deductible:

Liability:

Do you have a woodburning stove?:

Yes

No

Burglar or Fire Alarms?

Yes

No

Burglar or Fire Alarms? If yes select one:

Garage:

Yes

No

#Car(s)

Any other structures on property:

Yes

No

Amount of coverage::

Miles to Fire Department:

Fire Hydrants?

Yes

No

Distance from hydrant:

Is house visible by 5 other houses?

Yes

No

Swimming Pool?

Yes

No

Swimming Pool if yes is it:

Swimming Pool is it fenced in?

Yes

No

Trampoline

Yes

No

Member of any groups?:

Senior

College Gradate

Credit Union

Professional (teacher, engineers, CPA, doctor)

Other

Additional Comments:

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Homeowners Quote Highland

Customer Info:

Dwelling Info:

Additional Info: