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Exisitng Client - New Home Purchase Request Form


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

First Name
Required
Last Name
Required
Best contact phone number
Required
E-Mail Address
Required
Best method of contact
Required
Full legal address (If you are purchasing a new home, please input new purchase address)
Required
ZIP / Postal Code
Required
Have you been at this address for less than one year? (If the answer is yes, please input your previous address. If you are purchasing a new home, please input your current, soon-to-be prior address)
Required
Did you own or rent the above address? (Select N/A if it does not apply.
Required
If you own this property, will you be selling or renting it? (Type NA if not applicable)
Required
What is your date of birth?
Required
If married, please list your spouse's full legal name and date of birth. (If single, answer "N/A".)
Required
Is there anyone else listed on the deed? If so, please indicate name, relationship to you and date of birth.
Required
Number of Children
Optional
What is the closing date and/or the purchase date?
Required
/ /
What year was your home built?
Required
What is the style of your home?
Required



What is the square footage of the home? (Not including the basement or built-in garage)
Required
Is it built on basement, slab or crawlspace? What percentage?
Required
If there is a basement, what % is finished? Is it a walk-out?
Required
What is the home's construction type?
Required



What type of siding is on the home?
Required



What is the garage type and number of stalls? (Ex: Attached 2-stall, Detached 3-stall, built-in)
Required
Please describe all home claims made in the last 5 years? Please include date and reason for claim. (Type NA if not applicable)
Required
Do you have any outbuildings, such as a shed or barn? Please list size, value and condition (Type NA if not applicable).
Required
Do you have any items of high value that need to be scheduled on your policy? (Ex: jewelry, watches, fur, etc..)
Required
What group or association are you or your spouse a member of? (Check all that apply)
Optional




Do you and your spouse have a college degree? If so, what level of degree and where from? (Ex: Bachelors from University of Michigan)
Required
Please advise the year each of the following four categories were updated: Roof, Electrical/Wiring Box, Plumbing, HVAC/ furnace (to the best of your knowledge)
Required
Is there a pool, trampoline, fireplace, wood/pellet stove in the home?
Required
Do you have any pets? If so, advise how many and what kind/breed.
Required
Do you have a mortgage? If so, will it be escrow billed?
Optional
Additional Comments
Optional
Submission Validation
Required
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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5075 Cascade Rd SE, Suite 2A | Grand Rapids, MI 49546
Phone: 616-458-7808 | Fax: 616-458-8681
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