Customer Information

Name*

First Last

Email*

Phone*

Birth Date*

MM slash DD slash YYYY

Property Address*

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Is the property address the same as the mailing address?*

Yes

No

Mailing Address*

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Home Details

Number of Bedrooms*

Number of Bathrooms*

Square Feet*

Year Built*

Year Roof Last Replaced*

Number of Stories*

Purchase Price*

Purchase Date*

MM slash DD slash YYYY

Garage*

-Select-AttachedDetachedNone

Garage Size*

Location of HVAC

-Select-RoofSide

Foundation Type*

-Select-BasementSlabPier and beam pilingCrawl space

Fireplace Type

-Select-GasWoodElectricNone

Estimated Policy Start Date*

MM slash DD slash YYYY

Name of Current Insurer*

How many claims have you made over the past 3 years?*

-Select-0123+

Do you have a pool?

Yes

No

Is the pool secured or gated?*

Yes

No

Do you have a trampoline?

Yes

No

Is the home located in a gated community?

Yes

No

Do you have an alarm?

Yes

No

Do you have solar panels?

Yes

No

Do you have pets?

Yes

No

What breed of pet?*

Consent*

Yes, I agree to the Terms and Conditions**

SMS Opt-In

If you would also like to communicate via text, and agree to receive transactional and promotional messages from NMH Insurance Agency, please check this box.**

Comments

This field is for validation purposes and should be left unchanged.

*By checking Yes to the checkbox on this form, the user acknowledges the information provided is accurate to the best of their knowledge and that they want a quote for their home and/or auto. The consumer requests NMHIC Corp. evaluate their information and engage in working with various carriers to provide an insurance quote(s). They acknowledge they have not had a lapse in coverage for more than one month. If a lapse in coverage has been greater than one month, they must proceed to call 248.757.0665 to discuss with a licensed agent. NMHIC Corp. will only use the provided information to comply with its various carriers for the purpose of generating an insurance quote(s).

**Message and data rates may apply. Message frequency will vary, and you will be able to Opt-out by replying “STOP”. For more information on how your data will be handled, please visit our Privacy Policy. Our SMS Terms and Conditions can be viewed here.