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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: - Select - Mr. Mrs. Miss Ms.             First Name : Last Name:  Address: Address: City: State: AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip:  Daytime Phone: Evening Phone: Fax: E-mail Address: Underwriting Information Birth date:  Spouse's Birth date: 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? Select from list below ... College/University Alumni Michigan Home Builders Association Midwest Financial Credit Union AARP or Other Affiliated Retirement Organizations MEA CPA Trade Organizations Dental Trade Organizations Engineering Trade Organizations University of Michigan Employee Medical Employees

Policy Information Dwelling Coverage Amount/ Purchase Price (Market Value):  Personal Coverage Liability Amount: $500,000 $1,000,000 Deductible: $500 $1,000 $2,500 $5,000 Construction Information Year Built: Number of Stories: Number of Square Feet:   Wood   Brick   Stucco   Vinyl/Aluminum Siding Garage Type: 1 car 2 car 3 car Attached? Yes No Number of bathrooms: Basement? Yes No Basement Square Footage: Is Basement a Walkout? Yes No Is Basement Finished? Yes No If so, what percentage? Central Air Conditioning? Yes No Fireplace? Yes No   Number of Fireplaces: - Select - 0 1 2 3 4 5 UL* Approved Wood Stove? *UL = United Laboratories Yes No Deck? Yes No   Square Feet: Porch? Yes No   Square Feet: Breezeway? Yes No   Square Feet: Discounts Fire Extinguisher/Smoke Alarms/Dead Bolt Locks: Central Station Alarm? Yes No Non-Smoker: Yes No Fire Hydrant Within 1000 Feet? Yes No Do you operate a business in your home? Yes No If yes, please describe:   Valuable Articles Coverage Do you need extra coverage for fine arts, jewelry, guns, collectibles, and computers, other? Yes No If yes, please describe and include limit of insurance:   Underwriting Information Do have a swimming pool? Yes No   Is swimming pool above ground or inground? Above Ground Inground Diving Board? Yes No Slide? Yes No Approved fence for entire swimming pool area? Yes No Trampoline? Yes No Do you have a pet? Yes No Breed/Bite History Fuses? Yes No Knob or Tube Wiring? Yes No Do you have a hot tub or jacuzzi? Yes No   Do you keep the cover locked? Yes No 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.