Bingham Insurance Services

NEW QUOTES AND
POLICY REVIEW

Would you like to get a new quote or have us review your home or auto policy?

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Online Home Owners Insurance Review

PLEASE TAKE THE TIME TO FULLY COMPLETE THIS FORM.
Questions? Call Jeanne Way at 231-547-4062 or 1-800-748-0414, or email Jeanne.

Home Owners Insurance Questionnaire

Are you currently insured?		YES	NO
Current insurance company:
Mortgage Closing Date (if new):
Address of Home (Street, City, State, Zip):
	Year Built:
Is home ever rented?		YES	NO
Township & County:
Market Value:
Est. cost to rebuild:
Is there a basement?		YES	NO
Is it finished?		YES	NO
Previous Insurance Claims past 3 years:
Do you own any other properties?		YES	NO
Any smokers in household?		YES	NO
Detached buildings?		YES	NO
Describe detached buildings:
Any business operations on premises?		YES	NO
Wood stove?		YES	NO
If yes to wood stove, what type?
Dwelling square feet:
Miles to fire department:
Fire Hydrant within 1,000 feet?		YES	NO
Dead bolt locks?		YES	NO
Fire extinguishers?		YES	NO
Smoke detectors?		YES	NO
Central station burglar/fire alarm?		YES	NO
Name of responding Fire Department:
Jewelry, Fire Arms, Collectibles?		YES	NO
Boats, RVs or Snowmobiles?		YES	NO
Trampoline?		YES	NO
Pool?		YES	NO
If pool, what type?
Hot Tub?		YES	NO
Dogs?		YES	NO
If yes dogs, what breed?
Do you currently have an Umbrella policy?		YES	NO

Thank you for taking the time to complete this online review. We promise to get back to you shortly!

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Bingham Insurance Services · 200 Antrim Street, P.O. Box 318 · Charlevoix, Michigan 49720
Phone: 231-547-4062 or 1-800-748-0414 · Fax: 231-547-0655 · Email Us
Copyright 2011 Bingham Insurance Services. All Rights Reserved.
Member of Charlevoix Chamber of Commerce, Traverse City Chamber of Commerce & Beaver Island Chamber of Commerce
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