Request A Home Insurance Quote by mmcsx


More Info
									                                                 Request A Home Insurance Quote

Are You A Member of Indiana Members Credit Union                                                        Date of Birth

Name                                                                                Email or Phone #

Address (with County)                                                                                          Martial Status                 Housing

Address Of Home To Insure If Different

Year Home Was Built                      How Many Stories Is Your Home                   Exterior of Home                   Square Footage

Number of Bedrooms                  Bathroom                    Garages                    Type of Garage                       Garage Material

Mark Those That Apply - Required

  Living Room      Dining Room      Front Room            Basement         Slab         Crawl Space      Fireplace       Woodstove        Pool        Trampoline

If your home is over 15 years old, please indicate updates.

Electrical Type              Year Updated                          Furnace                   Year Updated                   Roof                  Year Updated

Replacement Value $                      Deductible Amount For Quote                         Current Insurance Carrier
                                           (Wind & Hail Claims are $1,000 Deductible)

Have There Been Any Claims or Losses On The Home In The Last 5 Years                             If So, Please List

Do You Have Any Pets? If So, Please List Them                                                           Bite History

Do You Have An Alarm System? If So, Is It Direct Reporting Or Monitored?

The Following Are Optional Coverages. Please Select The Ones You May Be Interested In.

  Back-up Of Sewer & Drain (A must for homes with basements)                               Earthquake (This adds back the exclusion of this coverage)
  Recreational Vehicle Coverage Such As Snowmobile, 4-Wheeler, or Jet Ski                  Scheduled Property Such As Jewelry, Furs, Artwork, Etc.


To top