MIRKES.COM
REQUEST HOME INSURANCE QUOTE HERE
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Name
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First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Email
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Phone Number
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Date of Birth (month/day/year)
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Gender
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Select
Male
Female
Marital Status
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Single
Married
Domestic Partner
Widowed
Separated
Divorced
Occupation
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Education
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Co-applicants: name, DOB, gender, occupation, & relation to you for anyone else in the home over 18. (If none, write none.)
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Swimming pool?
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Select
No
Yes
Trampoline?
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No
Yes
Any smoke/fire/burglar alarms? If so, are they professionally monitored?
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Any dogs? If so, what kind?
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Does anyone in the home smoke?
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Select
No
Yes
How many people live in the home?
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In an HOA?
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Have a fire extinguisher?
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Roof age, condition, material
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How much is your current annual premium?
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How did you hear about Mirkes Insurance?
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Age of heat/ac units
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Anything else you'd like to add?
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Submit