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General Information

* Required Field

Name*:

Address:

City: State: Zip:

Phone*: Fax:

Email*:

Type of Insurance you are looking for:

Commercial Personal Benefits

E-Mail Us:

 

It is only necessary to complete those areas of this form that relate to the types of insurance you want information on. To skip to the section you want, use the following quick links:


if you do not want homeowner's insurance, click here to skip this section.

Home Owners request for Information

Personal

Occupation:
Year of Construction:
Construction Type:
Any Wood Heat:
Type of Chimney:
Current type of Coverage:
City Limits:
Number of Miles from Fire Station:
Within a 1000 feet of a Fire Hydrant
Check if applicable:
Non-Smoker Dead Bolt  Locks

Fire Extinguishers

Alarms
Any scheduled items:

if you do not want auto insurance, click here to skip this section.

Auto request for Information

Name: Age:
  Vehicle 1 Vehicle 2
Year
Make
Model
V.I.N.
Primary Driver
Miles to Work

Additional Household Members:

Name
 Age
 Name
 Age
Name
 Age
 Name
 Age
Name
 Age
 Name
 Age
Please check coverage desired:
Bodily Injury/Property Damage:
Uninsured/Underinsured Motorist:
Comprehensive:
Collision:
Towing:
Rental Reimbursement:

 

Please check if any of these apply:
Air Bags
Good Student (B average or Better)
Home Owner
Tickets in the last 5 years

Anti-Lock Brakes: 

Accidents in the last 5 years

Anti-Theft Device


if you do not want life or health insurance, click here to skip this section.

Life or Health Insurance

Name Age
Tobacco Use    
Weight Height
Amount of Insurance    
Spouse Name Age  
Tobacco Use    
Weight Height
Child's Name Age
Child's Name Age
Child's Name Age
Health Conditions:  
Information About Other Insurance Needs:

if you do not want corporate insurance, click here to skip this section.

Corporate Insurance request for Information

Name:
Address:
City:       State:     Zip:
Phone:
Name of Business: 
Nature of Business:   
Insurance Renewal Date:

Number of employees:
Premium: 
Number of years experience in the field  
Current Insurance Carrier:  
How did you hear about us??

Please review your information and if correct, click send.  
If you need to start over click reset.  
 
Independent Insurance Agents & Consultants
Box Number 1000 + Birmingham, Michigan 48012-1000
Offices: 575 E. Maple Road + Troy, Michigan 48083
Area (248) 528-2400 + (800) 258-8065 + Fax (248) 528-2414
Monday-Friday 8am-5:30pm + Saturdays & Evenings by appointment
service@johnstonlewis.com