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Home Insurance Quote Form

Request a Free Home Insurance Quote

Protect your home and your peace of mind. Please provide the details below for an accurate, customized property quote.

A group of people are sitting around a table with laptops.

Request a Free Home Insurance Quote

Protect your home and your peace of mind. Please provide the details below for an accurate, customized property quote.

A group of people are sitting around a table with laptops and papers.

Request a Free Home Insurance Quote

Protect your home and your peace of mind. Please provide the details below for an accurate, customized property quote.

A group of people are sitting around a table with laptops.

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1. Contact & Transaction Details

Primary Contact Full Name:

Email Address:

Phone Number:

Property Address to Insure:

Is this a new home purchase?

Yes

No (If no, skip to Section 2)

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If yes:

Estimated Purchase Price:

Expected Closing Date:

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2. Home Construction & Systems

Year Built:

Square Footage: (Excluding Basement)

Roof Age: What year was the roof last replaced or updated?

Electrical Panel Type: Do you have any fuses in your home?

No, it has modern circuit breakers

Yes, there are fuses

Unsure

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3. Basement, Garage & Property Structures

Basement: Does your house have a basement?

No basement (Slab / Crawlspace)

Yes, it is Unfinished

Yes, it is Partially/Fully Finished

Estimated % finished (drywall, carpet, etc.):

Garage Type:

Attached Garage

Detached Garage

Carport

No Garage

Garage Size:

1-Car

2-Car

3+ Car

Other Outbuildings: Are there any other structures on the property? (e.g., sheds, pole barns, gazebos)

No

Yes

If yes, please describe size/type:

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4. Household & Safety Risks

Heating: Do you have a wood-burning or pellet stove?

No

Yes

Smoking Status: Is anyone in the household a smoker?

No

Yes

Pets: Do you have any dogs?

No

Yes

If yes, please list specific breeds:

Attractive Nuisances: Do you have any of the following on the property? (Check all that apply)

Swimming Pool

Pond

Trampoline

None of the above

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5. Insurance History & Preferences

Claims History: Have you had any property losses or insurance claims in the last 3 years?

No

Yes

If yes, please provide brief details/dates:

Current Coverage: What is your current home insurance coverage/dwelling limit?

Desired Deductible: Select your preferred policy deductible:

$1,000 Deductible

$2,500 Deductible

$5,000 Deductible

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Disclaimer: Submitting this form does not bind coverage. All quotes are subject to underwriter review and property history verification.

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Auto Insurance

Home Insurance

Business Insurance

Visit Us

4752 Occidental Hwy.

Adrian, MI 49221

Contact Us

Phone: (517) 423-8316

Fax: (517) 423-6280

Business Hours

Mon - Thu: 8:30 am - 5:00 pm
Friday: 8:30 am - 4:30 pm
Sat - Sun: Closed

Auto Insurance

Home Insurance

Business Insurance

Visit Us

4752 Occidental Hwy.

Adrian, MI 49221

Contact Us

Phone: (517) 423-8316

Fax: (517) 423-6280

Business Hours

Mon - Thu: 8:30 am - 5:00 pm
Friday: 8:30 am - 4:30 pm
Sat - Sun: Closed

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All Rights Reserved | Hayes Insurance Agency

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