Our reputation is built on integrity, knowledge and hard work.

Trusted Choice
What is this?

Online Homeowners Insurance Review

PLEASE TAKE THE TIME TO FULLY COMPLETE THIS FORM. We will use the confidential facts that you provide to better protect your home, personal property, and personal liability.
Questions? Call Jeanne Way at 231-547-4062 or 1-800-748-0414, or email Jeanne.

Business Activities

Are there any business activities operated out of your home?

	NO BUSINESS ACTIVITIES
	Babysitting / Child Care
	Hair Salon / Nail Salon
	Piano Lessons
	Produce Stands or Garage / Yard Sales
	Home-based Office [enter details in comments below]

Enter comments or details on any business activities below...

Improvements or Upgrades

Were there any recent improvements or upgrades to your home?

	NO IMPROVEMENTS OR UPGRADES
	Kitchen
	Bathroom
	Heating / Air
	Plumbing
	Electrical
	Roof
	Swimming Pool
	Windows
	Patio / Deck
	Garage / Carport
	Addition / Extension

Enter comments or details on any improvements or upgrades below...

Valuable Possessions

Do you own or lease any of the following?
Include items we may already insure plus any new items recently acquired.

	NONE
	Boat
	Fine Art / Collectibles
	Jewelry / Silverware / Furs
	Computer and Software
	Cellular Phone / Pager / PDA
	Snowmobile / Golf Cart / Other Recreational Vehicles
	Firearms

Enter comments or details on any valuable possessions below...

Outside Activities

Are you or members of your family active as a...

	NOT ACTIVE IN ANY OF THE FOLLOWING
	Committee Member
	Board Member
	Sports Team Coach / Umpire / Organizer / Fund Raiser
	School Class Organizer / Fund Raiser / General Volunteer

Enter comments or details on your personal activities below...

Security Information

Which protections do you have installed in your home?

Smoke detectors on each floor:	Hard-wired with battery backup	Battery-Only
Fire Alarm:	Central Station	Local-Only
Burglar Alarm:	Central Station	Local-Only
Deadbolts on all outside doors:
Fire Extinquisher:

Miscellaneous Information

Check the following boxes only if your answer is YES...

	I have a wood-burning stove or similar secondary heating unit.
	I own one or more rental properties.
	I have a swimming pool or trampoline.
	I employ domestic help [maid, gardener, etc.].
	I have one or more dogs on my property [specify breeds in the comment section below].

Enter comments regarding the above or on any other topic...

Extra Protection

Check off the extra coverages on which you would like information:

	Automobile Insurance
	$1,000,000 Umbrella Policy (or higher)
	Business Insurance
	Identity-Theft Insurance
	Low-Cost Term Life Insurance
	Retirement Planning / College Funds
	Health Insurance / Personal Income Protection
	Motorcycle Insurance / RV / Snowmobile / Golf Cart
	Boat Insurance
	Flood Insurance
	College Savings Plans
	Personal Income Protection
	Long-Term Care

Yes! I am interested in information on the above protection. Please contact me by ...
Email Regular Mail Phone [Enter numbers below]

Form was completed by:

Your Name*:
Street Address:
City,State,Zip:
Day Phone:
Evening Phone:
Email Address*:

* Required Fields

Enter any other comments below...

Thank you for taking the time to complete this online review. Its purpose is to assist us in determining if your homeowners insurance needs some tuning to match up with the current conditions in your home and personal life. We promise to get back to you shortly!

Back to Services Page

: Our Services : News/Events : F.A.Q.s : Contact Us : Home :
: Privacy Policy :

Bingham Insurance Services • 207 Ferry Avenue, P.O. Box 318 • Charlevoix, Michigan 49720
Need a map? • Ph: 231-547-4062 or 1-800-748-0414 • Fax: 231-547-0655 • Email Us