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:
Occupation:
	- Denotes a required field.

Basic Coverage Information:
Construction:
Year Built:	(i.e. 1995)
Usage:
Policy Type:
Style of Home:
Personal Liability:
Deductible:
Dwelling Coverage (on current policy):	(of current policy)
Market Value of Home:	(i.e. $200,000)
Total Square Feet:	(i.e. 2,500)
Foundation Type:
Garage Type:
Responding Fire Department:
Miles to Fire Department:
City Water:
Supplemental Heat Source:
If Yes, please select:

Scheduled Personal Property: (i.e., Jewelry Riders - optional)
Please enter any scheduled items:

Protective Devices / Credits:
Burglar Alarm:
Fire Alarm:
Deadbolt:
Fire Extinguishers:
Are any members of household smokers:
For possible credits, please list memberships in Credit Unions, professional organizations, AARP, Co-Ops, etc:

Underwriting:
	Year of repair or replacement:
Electrical:	(i.e. 1995)
Roof:	(i.e. 1995)
Plumbing:	(i.e. 1995)
Heating:	(i.e. 1995)
Do you own a dog (if yes, type of breed):	(i.e. Yes, Poodle)
Swimming Pool:
Type of Wiring:
Losses in past 5 years:
Describe Losses:

Additional Information:
Who is your current insurance carrier:
When does your policy expire:
Your current 12 month premium cost:
How did you hear about us:
Name of referring company or individual: