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Great Northern Insurance Agency
Our Dedication Ensures Your Satisfaction

CALL NOW 248-856-9000

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Inland Marine

Our process is transparent

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

PERSONAL INFORMATION

Fields marked (*) are mandatory

APPLICANT'S NAME

ADDRESS

CITY

STATE

ZIP

DAY PHONE

NIGHT PHONE

BEST TIME TO CALL

EMAIL ADDRESS

APPLICANT AND LOCATION INFORMATION

Fields marked (*) are mandatory

AGE

MARITAL STATUS

Married Single

OCCUPATION

SPOUSE'S OCCUPATION

TERRITORY CODE (IF KNOWN)

PROTECTION CLASS (IF KNOWN)

FIRE DISTRICT/ CODE # (IF KNOWN)

LOCATION OF PROPERTY (IF DIFFERENT FROM ABOVE)

CHECK IF THERE IS ADDITIONAL LOCATION

DWELLING TYPE(S)

CONSTRUCTION TYPE(S) (IF KNOWN)

# FAMILIES (IN EACH LOCATION)

OTHER RELEVANT INFO

COVERAGES

Jewelry

AMOUNT ($)

Furs

AMOUNT ($)

Fine Arts

AMOUNT ($)

Cameras

AMOUNT ($)

Musical Instruments

AMOUNT ($)

Silverware

AMOUNT ($)

Stamps

AMOUNT ($)

Coins

AMOUNT ($)

Golfer's Equipment

AMOUNT ($)

ADDITIONAL COVERAGE

AMOUNT ($)

ADDITIONAL COVERAGE

AMOUNT ($)

ADDITIONAL COVERAGE

AMOUNT ($)

ADDITIONAL COVERAGE

AMOUNT ($)

UNATTENDED CAR COVERAGE (STAMPS/COINS)

BROAD FORM PAIR & SET COVERAGE

NON-MOBILE ORGAN COVERAGE

SAFE CREDIT (IDENTIFY PROPERTY, SAFE CLASS, ETC)

ACV LOSS SETTLEMENT

REPLACEMENT COST LOSS SETTLEMENT

BREAKAGE COVERAGE (*ON SCHEDULE)

BLANKET COVERAGE

ADDITIONAL RATING INFORMATION

GENERAL INFORMATION

ANY PROTECTIVE DEVICES/SYSTEMS IN USE?

Yes No

WILL ANY PROPERTY BE EXHIBITED?

Yes No

WILL ANY SPECIAL RESTRICTION/ ENDORSEMENTS APPLY?

Yes No

WILL ANY TYPE OF DEDUCTIBLE APPLY?

Yes No

IS ANY PROPERTY USED PROFESSIONALLY/ COMMERCIALLY?

Yes No

ANY OTHER INSURANCE WITH THIS COMPANY?

Yes No

DID ANY LOSS OCCUR DURING THE LAST 3 YEARS?

Yes No

ANY COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE LAST 3 YEARS? NOT APPLICABLE IN MO

Yes No

PRIOR INSURER & POLICY NUMBER

REMARKS

SCHEDULE OF PROPERTY

Provide a detailed description of each item, from whom purchased, etc. Be sure to forward all required appraisals/bills.

#

DESCRIPTION

PURCHASE/ APPRAISAL DATE

AMOUNT OF INSURANCE ($)

#

DESCRIPTION

PURCHASE/ APPRAISAL DATE

AMOUNT OF INSURANCE ($)

#

DESCRIPTION

PURCHASE/ APPRAISAL DATE

AMOUNT OF INSURANCE ($)

#

DESCRIPTION

PURCHASE/ APPRAISAL DATE

AMOUNT OF INSURANCE ($)

#

DESCRIPTION

PURCHASE/ APPRAISAL DATE

AMOUNT OF INSURANCE ($)

#

DESCRIPTION

PURCHASE/ APPRAISAL DATE

AMOUNT OF INSURANCE ($)

#

DESCRIPTION

PURCHASE/ APPRAISAL DATE

AMOUNT OF INSURANCE ($)

#

DESCRIPTION

PURCHASE/ APPRAISAL DATE

AMOUNT OF INSURANCE ($)

#

DESCRIPTION

PURCHASE/ APPRAISAL DATE

AMOUNT OF INSURANCE ($)

#

DESCRIPTION

PURCHASE/ APPRAISAL DATE

AMOUNT OF INSURANCE ($)

#

DESCRIPTION

PURCHASE/ APPRAISAL DATE

AMOUNT OF INSURANCE ($)

#

DESCRIPTION

PURCHASE/ APPRAISAL DATE

AMOUNT OF INSURANCE ($)

ADDITIONAL COMMENTS

ADDITIONAL COMMENTS

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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