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Home Insurance Application
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Name
*
First
Last
Phone
*
Layout updated?) Residence?
Email
*
Preferred Method of Contact
Call
Text
Email
City, State (Illinois only)
*
Property Type
*
Single-Family Home
Condo
Townhome
Landlord / Rental Property
Renters Insurance
Property Details
Property Address
*
Year Built
*
Square Footage
*
Number of Stories
*
Primary Residence?
*
Yes
No
Construction Details
Roof Type & Year Updated
*
Exterior Type (Brick, Vinyl, Wood, etc.)
*
Heating Type (year updated?)
*
Electrical Type (year updated?)
*
Plumbing Type (year updated?)
*
Occupancy
Owner Occupied / Tenant Occupied / Vacant
*
Short-Term Rental?
*
Yes
No
Claims History
Any property claims in last 5 years?
*
Yes
No
Consent
I agree to be contacted by Merrill Insurance Agency, Inc. regarding my quote request.
Submit
