Home & Auto Quote

REQUEST HOME & AUTO INSURANCE QUOTE HERE

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Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Date of Birth (month/day/year) *

Drivers License # *

Gender *

Marital Status *

Occupation *

Education *

Co-applicants: name, DOB, DL#, gender, occupation, & relation to you for any other drivers on the auto policy. (If none, write none.) *

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? *

Car #2 (if applicable): year/make/model? Name of primary driver? Annual miles? Loan, lease, or paid for? *

Car #3 (if applicable): year/make/model? Name of primary driver? Annual miles? Loan, lease, or paid for? *

Car #4 (if applicable): year/make/model? Name of primary driver? Annual miles? Loan, lease, or paid for? *

In addition to liability coverage, what else would you like? *

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? *

Swimming pool? *

Trampoline? *

Any dogs? If so, what kind? *

Any smoke/fire/burglar alarms? If so, are they professionally monitored? *

How much is your current annual home insurance premium? *

Does anyone in the home smoke? *

Have a fire extinguisher? *

In an HOA? *

How many people live in the home? *

How did you hear about Mirkes Insurance? *

Age of heat/ac units *

Roof age, material, condition *

Anything else you'd like to add? *

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