|| Hylant Group - Insurance, Risk Management, Consulting ||

If you would prefer to speak with an Agent instead of completing this online form, please call Hylant Group of Ann Arbor at
734-741-0044. All fields are required for an accurate quote otherwise an agent will need to contact you for additional information. Thank you!

General Information

Title:

First Name :

Last Name:

Address:

City:

State:

Zip:

Daytime Phone:

Evening Phone:

Fax:

E-mail Address:

Underwriting Information

Birthdate:

Spouse's Birthdate:

Occupation:

Spouse's Occupation:

Social Security Number:

Spouse's Social Security Number:

As part of the application process, we will order credit and prior loss reports. This information will be used to evaluate your application. You may request a written statement describing our use of credit histories or insurance scores contained within our Credit Brochure. Please confirm for me that you are authorized to initiate this insurance transaction and obtain consumer reports on behalf of yourself and your spouse, if applicable, or other individuals who will be insured under the policy.

Do you belong to any of the following groups?

Policy Information

Dwelling Coverage Amount/ Purchase Price (Market Value):
Personal Coverage Liability Amount:
Deductible:

Construction Information

Year Built:

Number of Stories:

Number of Square Feet:

Wood

Brick

Stucco

Vinyl/Aluminum Siding

Garage Type:

Attached?

Number of bathrooms:

Basement?

Basement Square Footage:

Is Basement a Walkout?

Is Basement Finished?

If so, what percentage?

Central Air Conditioning?

Fireplace?

Number of Fireplaces:

UL* Approved Wood Stove?
*UL = United Laboratories

Deck?			Square Feet:
Porch?			Square Feet:
Breezeway?			Square Feet:

Discounts

Fire Extinguisher/Smoke Alarms/Dead Bolt Locks:
Central Station Alarm?
Non-Smoker:
Fire Hydrant Within 1000 Feet?
Do you operate a business in your home?
If yes, please describe:

Valuable Articles Coverage

Do you need extra coverage for fine arts, jewelry, guns, collectibles, and computers, other?
If yes, please descibe and include limit of insurance:

Underwriting Information

Do have a swimming pool?
	Is swimming pool above ground or inground?
Diving Board?
Slide?
Approved fence for enire swimming pool area?
Trampoline?
Do you have a pet?
Breed/Bite History
Fuses?
Knob or Tube Wiring?
Do you have a hot tub or jacuzzi?
	Do you keep the cover locked?

If Your Home Was Built Before 1980 Please Provide the Year the Following Were Last Updated

Roof:
Electrical:
Heating:
Plumbing:

Please note that no coverage can be bound, changed, or deleted via this web site. You may make a request.
However, any request is not deemed effective until a formal verification is sent to you from our office.