Free No-Obligation Business Quote :: Kalamazoo, Portage and Southwest Michigan (MI)

General Information
Name
Social Security #
Date of Birth
Email
Address
City
State		Zip
Township
Phone
Exterior
Construction
Stories (not incl basement)
Year Built
Sq Footage (not incl basement)
Foundation Type %	Slab Crawl Space Basement Finished Walk Out
Attached Structures Size	Open Porch Closed Porch Screened Porch Wood Deck
Exterior Wall Type %	Brick Alum Siding Wood Vinyl Siding Other
Roofing Type
Garage	1 car 1-1/2 car 2 car 2-1/2 car 3 car Other
Number of Baths
Central Air	Yes No
Year Roof Updated
Interior
Flooring %	Hardwood Carpet (Acrylic/NY) Carpet (Berber/WO) Vinyl	Ceramic Tile Parquet Laminated Other
Other
Fireplace	Yes No
Woodstove	Yes No
Jewelry/Guns/Furs
Disclaimer Notice: The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, not does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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Whitaker-LaChance Agency
2176 East Centre Ave.
PO Box 1806
Portage, MI 49081-1806
Toll Free: 800.968.1959
Phone: 269.324.7700
Fax: 269.324.5660