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Great Northern Insurance Agency
Our Dedication Ensures Your Satisfaction

CALL NOW 248-856-9000

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Contact Us

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Contact Us

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Our process is transparent

For Help Call 1-(248)-856-9000

Fields marked (*) are mandatory.

FIRST NAME
your first and last name should reflect your legal name as registered on the vehicles you own and for which you wish to purchase insurance.

MIDDLE NAME

LAST NAME

STREET ADDRESS

CITY

STATE

ZIP

HOME PHONE

WORK PHONE

REFERRED BY

AGENT NAME OR PROMO CODE

E-MAIL ADDRESS

HAVE PRIOR INSURANCE FROM CARRIER

IF OTHER IS SELECTED PLEASE FILL THE CARRIER'S NAME

HAVE INSURANCE WITH THAT CARRIER FOR

ESTIMATED YEARLY PREMIUM (IN US$)

POLICY ENDS ON

NUMBER OF LICENSED DRIVERS

NUMBER OF VEHICLES

RESIDENCE TYPE

VEHICLE 1

Fields marked (*) are mandatory.

YEAR

MAKE

MODEL

VEHICLE ID #

ANNUAL MILEAGE (EST)

VEHICLE USE

MILES TO WORK/SCHOOL (1 WAY)

ANTI-THEFT DEVICE CATEGORY

IS VEHICLE FOUR WHEEL DRIVE

Yes No

BODY TYPE

CYLINDERS

DOES VEHICLE HAVE EXISTING DAMAGE OR NEEDS REPAIRS

Yes No

VEHICLE 2

YEAR

MAKE

MODEL

VEHICLE ID #

ANNUAL MILEAGE (EST)

VEHICLE USE

MILES TO WORK/SCHOOL (1 WAY)

ANTI-THEFT DEVICE CATEGORY

IS VEHICLE FOUR WHEEL DRIVE

Yes No

BODY TYPE

CYLINDERS

DOES VEHICLE HAVE EXISTING DAMAGE OR NEEDS REPAIRS

Yes No

VEHICLE 3

YEAR

MAKE

MODEL

VEHICLE ID #

ANNUAL MILEAGE (EST)

VEHICLE USE

MILES TO WORK/SCHOOL (1 WAY)

ANTI-THEFT DEVICE CATEGORY

IS VEHICLE FOUR WHEEL DRIVE

Yes No

BODY TYPE

CYLINDERS

DOES VEHICLE HAVE EXISTING DAMAGE OR NEEDS REPAIRS

Yes No

VEHICLE 4

YEAR

MAKE

MODEL

VEHICLE ID #

ANNUAL MILEAGE (EST)

VEHICLE USE

MILES TO WORK/SCHOOL (1 WAY)

ANTI-THEFT DEVICE CATEGORY

IS VEHICLE FOUR WHEEL DRIVE

Yes No

BODY TYPE

CYLINDERS

DOES VEHICLE HAVE EXISTING DAMAGE OR NEEDS REPAIRS

Yes No

Please Enter the Multiple Devices on Your Vehicle (check all applicable)

Alarm System Security Battery Active Disabling Electronic Tracking Etched Window Fuel Cut-Off Hood Lock Ignition Cut-Off Steering Lock Passive Disabling Shaker Switch Window ID Other Anti-Theft Device

Fields marked (*) are mandatory.

FIRST NAME

MIDDLE NAME

LAST NAME

DATE OF BIRTH

RELATIONSHIP TO APPLICANT

SEX

Male Female

DRIVER LICENSE #

ISSUED IN STATE

YEARS LICENSED IN US

AGE FIRST LICENSED

MARITAL STATUS

OCCUPATION

YEARS WITH CURRENT EMPLOYER

PRIMARY VEHICLE DRIVEN

CURRENT LICENSE STATUS

DUI OR DWI LAST 5 YEARS

Yes No

HAS YOUR LICENSE BEEN SUSPENDED OR REVOKED IN THE LAST 5 YEARS

Yes No

DO YOU REQUIRE A SR-22

Yes No

NUMBER OF VIOLATIONS IN THE LAST 3 YEARS

NUMBER OF ACCIDENTS IN THE LAST 5 YEARS

SSN#

RATE YOUR CREDIT

ACCIDENTS

DRIVER NAME

ACCIDENT DATE

BI PRESENT

ACCIDENT DESCRIPTION (MAX 100 CHAR)

DRIVER NAME

ACCIDENT DATE

BI PRESENT

ACCIDENT DESCRIPTION (MAX 100 CHAR)

DRIVER NAME

ACCIDENT DATE

BI PRESENT

ACCIDENT DESCRIPTION (MAX 100 CHAR)

VIOLATIONS

DRIVER NAME

VIOLATION DATE

CODE

CODE

DRIVER NAME

VIOLATION DATE

CODE

CODE

DRIVER NAME

VIOLATION DATE

CODE

CODE

POLICY LIMITS/DEDS

Fields marked (*) are mandatory.

BODILY INJURY

PROPERTY DAMAGE

PIP/ MEDICAL PAYMENTS

UNINSURED MOTORIST

UNDERINSURED MOTORIST

VEHICLE 1

COMPREHENSIVE

COLLISION

TOWING EXPENSES

Yes

RENTAL COVERAGE
available if you choose comprehensive

Yes

VEHICLE 2

COMPREHENSIVE

COLLISION

TOWING EXPENSES

Yes

RENTAL COVERAGE
available if you choose comprehensive

Yes

VEHICLE 3

COMPREHENSIVE

COLLISION

TOWING EXPENSES

Yes

RENTAL COVERAGE
available if you choose comprehensive

Yes

VEHICLE 4

COMPREHENSIVE

COLLISION

TOWING EXPENSES

Yes

RENTAL COVERAGE
available if you choose comprehensive

Yes

Products

Services

Locations

Products

Auto Quote
Homeowners Quote
Condominium insurance
Renters Insurance
Commercial Auto
Business Owners (BOP)
General Liability
Inland Marine
Liquor Liability

Services

Change Address
Add Vehicle
Delete Vehicle
Change Vehicle
Add Driver
Delete Driver
General Auto Request
File Auto Claim
General Home Request
File Property Loss

Locations

Main Office
ISU-Great Northern Insurance Agency 39850 Van Dyke Ave Sterling Heights , MI 48313
Phone:248-856-9000
Fax:248-856-9001
California Office
Kevin Lam 1900 Camden Ave San Jose, CA 95124
Phone:(408) 444-5196
Fax:(877) 275-1639
Ann Arbor Office
Kristine Reed PO Box 3306 Ann Arbor, MI 48106
Phone:(734)945-0027
Phone2:(248)856-9000
Fax:(248)856-9001

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