Knabusch Insurance Services, Inc. - Auto Insurance, Home Insurance, Flood Insurance, Life Insurance, Health Insurance

If you would like to receive an Insurance Quote, please complete the form below. Once your information is received we will process the information and then contact you to review your current insurance coverage and premium. Quotes provided for Michigan and Ohio residence only.

Disclaimer: This is not a final quote, nor is it an offer of insurance. Any quote is based only upon the rating information you have provided and may be subject to additional rating variables. This is for informational purposes only. This is not a contract and insurance coverage is not being provided. All information is kept completely confidential.

Your Address Information:
Full Name:
Date of Birth:
Marital Status:
Social Security Number:
Address 1:
Address 2:
City:
State:
Zip Code:	(5 or 9 digits)
Home Telephone:
Work Telephone:
Email Address:
Preferred Method of Contact:
	- Denotes a required field.

Liability Coverage Choices:
Bodily Injury:
Property Damage:
Number of Household Dependents:
Do you have Health Insurance:
Primary Residence:

Driver Information:
Note: If additional Drivers are added, you must include their Social Security numbers.

Driver 1:
Full Name:
Date of Birth:
Marital Status:
Occupation:
Drivers License Number:
Social Security Number:
Accidents/Violations:	(if yes specify below)
Last 5 years:
Date and Incident 1:
Date and Incident 2:
Date and Incident 3:


Driver 2:
Full Name:
Date of Birth:
Marital Status:
Occupation:
Drivers License Number:
Social Security Number:
Accidents/Violations:	(if yes specify below)
Last 5 years:
Date and Incident 1:
Date and Incident 2:
Date and Incident 3:


Driver 3:
Full Name:
Date of Birth:
Marital Status:
Occupation:
Drivers License Number:
Social Security Number:
Accidents/Violations:	(if yes specify below)
Last 5 years:
Date and Incident 1:
Date and Incident 2:
Date and Incident 3:

Vehicle Information:
Vehicle 1:
Year:	(i.e. 2004)
Make:	(i.e. Honda)
Model:	(i.e. Accord)
VIN:	(17 digits)
Name on Title:
Number of Doors:
Anti-Theft Devices:
If yes, what type?
Primary Use:
Primary Driver of this Vehicle:
Vehicle 1 Coverage:
Comprehensive Deductible:
Collision Deductible:
Collision Type:
Rental Reimbursement:
Towing and Labor:


Vehicle 2:
Year:	(i.e. 2004)
Make:	(i.e. Honda)
Model:	(i.e. Accord)
VIN:	(17 digits)
Name on Title:
Number of Doors:
Anti-Theft Devices:
If yes, what type?
Primary Use:
Primary Driver of this Vehicle:
Vehicle 2 Coverage:
Comprehensive Deductible:
Collision Deductible:
Collision Type:
Rental Reimbursement:
Towing and Labor:


Vehicle 3:
Year:	(i.e. 2004)
Make:	(i.e. Honda)
Model:	(i.e. Accord)
VIN:	(17 digits)
Name on Title:
Number of Doors:
Anti-Theft Devices:
If yes, what type?
Primary Use:
Primary Driver of this Vehicle:
Vehicle 3 Coverage:
Comprehensive Deductible:
Collision Deductible:
Collision Type:
Rental Reimbursement:
Towing and Labor:

Additional Information:
Who is your current insurance carrier:
When does your policy expire:
Your current 6 month premium cost:
How did you hear about us:
Name of referring company or individual:
For possible credits, please list memberships in Credit Unions, professional organizations, AARP, Co-Ops, etc:

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Providing Auto Insurance, Home Insurance, Life Insurance, Flood Insurance, Individual Health Insurance, Group Health Insurance as well as Commercial Insurance to businesses and residents in Southeast Michigan and Norwest Ohio areas. Some of the cities we serve include: Monroe, Dundee, Temperance, Erie, Newport, Lasalle, Milan, Lambertville, Petersburg, Ottawa Lake, Maybee, Flat Rock, South Rockwood, Carleton, Romulus

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