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Great Northern Insurance Agency
Our Dedication Ensures Your Satisfaction

CALL NOW 248-856-9000

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Contact Us

Life Quote

Our process is transparent

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

GENERAL INFORMATION

Fields marked (*) are mandatory

AMOUNT OF COVERAGE
(Note: Can be changed later)

FIRST NAME

MIDDLE NAME

LAST NAME

STREET ADDRESS

CITY

STATE OF RESIDENCE

ZIP

HOME PHONE

YEAR

GENDER

Male Female

DATE OF BIRTH

HEIGHT (FT./IN.)

WEIGHT

MATRIAL STATUS

US LEGAL STATUS

E-MAIL ADDRESS

LIFE STYLE INFORMATION

Fields marked (*) are mandatory

YOU ARE A PILOT

YOU ARE CURRENTLY ON ACTIVE MILITARY DUTY

YOU HAVE HAZARDOUS OCCUPATION

YOU HAVE HAZARDOUS HOBBY/AVOCATION

YOU INTEND TO TRAVEL TO A POLITICALLY UNSTABLE COUNTRY

DRIVING RECORD-HAVE YOU HAD ANY VIOLATIONS IN LAST 5 YEARS

Yes No

CIGARETTE USAGE

HAVE YOU USED TOBACCO PRODUCT WITH IN THE LAST 10 YEARS

Yes No

MEDICAL HISTORY

Fields marked (*) are mandatory

SYSTOLIC RATING

DIASTOLIC RATING

RECEIVED BLOOD PRESSURE TREATMENT

Yes No

RECEIVED CHOLESTEROL TREATMENT

Yes No

HAVE ANY OF YOUR IMMEDIATE FAMILY MEMBERS HAD ANY OF THE FOLLOWING: HEART ATTACK, DIABETES, STROKE, CANCER, OR KIDNEY DISEASE
(Note: immediate family members refer to mother, father or siblings)

Yes No

Check any of the following conditions for which you have been diagnosed or treated

CENTRAL NERVOUS SYSTEM

ALZHEIMER'S DISEASE

EPILEPSY

MULTIPLE SCLEROSIS

PARKINSON'S DISEASE

CIRCULATORY SYSTEM

CORONARY ARTERY DISEASE

STROKE

VASCULAR DISEASE

OTHER HEART DISEASE

DIGESTIVE SYSTEM

BOWEL INCONTINENCE

KIDNEY DISEASE

DIABETES MELLITUS

GASTRIC/PEPTIC ULCERS

KDNEY STONES (LAST 2 YEARS)

NEUROGENIC BLADDER

ULCERATIVE COLITIS OR ILEITIS

MENTAL HEALTH, DRUG ABUSE

DRUG ABUSE

DEPRESSION (LAST 2 YEARS)

MENTAL ILLNESS

ALCOHOLISM

RESPIRATORY SYSTEM

ASTHMA

CHRONIC BRONCHITIS

EMPHYSEMA

SLEEP APNEA

COPD

CANCER

LEUKEMIA

BASAL CELL

SQUAMOUS CELL

MELANOMA

PROSTATE CANCER

BREAST CANCER

OTHER CANCER

OTHER

HIV

RHEUMATOID ARTHRITIS

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Locations

Products

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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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