MIRKES.COM
REQUEST HOME & AUTO INSURANCE QUOTE HERE
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Name
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First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Email
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Phone Number
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Date of Birth (month/day/year)
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Drivers License #
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Gender
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Select
Male
Female
Marital Status
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Select
Single
Married
Domestic Partner
Widowed
Separated
Divorced
Occupation
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Education
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Co-applicants: name, DOB, DL#, gender, occupation, & relation to you for any other drivers on the auto policy. (If none, write none.)
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Car #1: What year/make/model? (Provide VIN if you have it) Name of primary driver? Approx # of annual miles? Loan, lease, or paid for?
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Car #2 (if applicable): year/make/model? Name of primary driver? Annual miles? Loan, lease, or paid for?
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Car #3 (if applicable): year/make/model? Name of primary driver? Annual miles? Loan, lease, or paid for?
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Car #4 (if applicable): year/make/model? Name of primary driver? Annual miles? Loan, lease, or paid for?
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In addition to liability coverage, what else would you like?
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Comprehensive (covers losses other than collision i.e. hail damage)
Collision (covers damage to your car when in an accident that is your fault)
Uninsured/Underinsured Motorist (covers you if the person who hits you has little or no insurance)
Towing
Rental Car
Personal Injury Protection (pays for medical bills and lost wages)
Medical Payments (just pays for medical bills)
I'm not sure
How much is your current annual auto insurance premium?
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Swimming pool?
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Select
No
Yes
Trampoline?
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Select
No
Yes
Any dogs? If so, what kind?
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Any smoke/fire/burglar alarms? If so, are they professionally monitored?
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How much is your current annual home insurance premium?
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Does anyone in the home smoke?
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Select
No
Yes
Have a fire extinguisher?
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In an HOA?
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How many people live in the home?
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How did you hear about Mirkes Insurance?
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Age of heat/ac units
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Roof age, material, condition
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Anything else you'd like to add?
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Submit