Baker Insurance Agency - Lennon, Michigan

Today's Date:

Name:		DOB:
Spouse Name:		DOB:
Mailing Address:		City/State/Zip:
Email:		Home Phone:
Business Phone:		Fax:
Cell:		Contact Preference:
Current / Prior Insurance Company		Expires:
Policy #:		Insured Address:
Sq Ft:		Year Built:
Construction (Masonry-block, Frame, Stucco Vaneer):		# of Bedrooms:
# of Bathrooms:		Miles to Fire dept
Garage / Carport:		Fireplace:
Recreational Vehicles:		Deadbolt Locks:
Smoke Detectors / Fire Extinguishers:		Roof (Shingle, Tile, Other):
Older home upgrade year:		Other structures:
Purchase Price:		Value:
Purchase / Closing Date:		Mortgage Company:
Mortgage Contact:		Phone:
Mortgage Email:		Loan #:

Baker Insurance Agency,
11931 Main Street, P.O. Box 6, Lennon, MI 48449, 800-895-7228, 810-621-3400, 810-621-3406-fax,email

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