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Request a Home Insurance Quote

CITIZENS INSURANCE and White, Eby & Rajala are happy to make it easy for you to get a quote on the insurance you need.

Please complete the information in this form and click on Submit. Feel free to call us at 810.234.4628 if you have any questions at all.

We will contact you by phone to review your information and provide an insurance quote tailored to your needs.

Name
Address
City
State
Zip
County
Phone
Fax
Email

Home Description

Construction	Brick	Frame	Aluminum
Year Built

Please advise the date the following items have been updated if home is over 20 years old:

Plumbing
Heating
Electrical
Roof

Is your home within 3 miles from a fire station?

Yes No

Is your home within 500 feet from a fire hydrant?

Yes No

Do you have smoke detectors?

Yes No

Do you have fire extinguishers?

Yes No

Do you want replacement cost coverage on your contents?

Yes No

Are you a non-smoker?

Yes No

If you own autos, would you be interested in combining the autos with the homeowners policy for additional discounts?

Yes No

Coverage Limits

Dwelling
Contents
Liability
Deductible

List any items which you desire to have scheduled for an agreed amount ,
i.e. jewelry, furs, silverware:

General Information

Have you had any homeowner claims or losses within the last 3 years?
If so, please explain:

Do you have a swimming pool?	Yes	No
If so, is the pool completely fenced in?	Yes	No
Current policy expiration date?

Any Additional Comments:

new home

Quote Form Notes

When communicating with us via e-mail, please do not send any information that is considered confidential or sensitive in nature (social security number, account number, etc.) Please feel free to contact us by phone at 810.234.4628.