Contact 1 — The Jessica Artibee Agency

Please complete the following form if you would like a quote for auto and home insurance

Name

First Name

Last Name

Date of Birth: mm/dd/yyyy

Phone

(###)

###

####

Address

Drivers License #

Spouses Name (If Applicable)

Spouse's Date of Birth: mm/dd/yyyy

Vehicle #1 Info (Year, Make, Model)

Vehicle #2 Info (Year, Make, Model)

Vehicle #3 Info (Year, Make, Model)

Please list and additional drivers and vehicles here

Please list all tickets rom the last three years here (If applicable)

Do you drive for a profit? (Doordash, GrubHub, Uber)

Yes

Do you own or rent your home?

Own

Rent

I don't own or rent

What year was your home built?

Square Feet

Stories

Finished Basement?

Yes

Please list and special features about your home that may increase it's value.

1300 N. Waverly Rd. Lansing MI, 48917

Hours
Monday–Friday
8:30AM-4:40PM

Phone
517-833-4476