Lighthouse Insurance Agency, LLC.

Home

About Us

Companies Represented

Commercial Insurance

Personal Insurance

Contact Us

First Name:
Last Name:
Date of Birth:
Social Security Number:
Spouse’s Name:
Spouse’s Date of Birth:
Spouse’s Social Security Number:
Phone Number:
Email Address:
Preferred Method of Contact:	Phone Email
Current Address:
Any Household Members Smokers?:	Yes No
Home Information
Property Address:
Purchase Price:
Square Footage:
Year Built:
Type of Construction:	Frame Brick
Style of Home:
Fireplace:	Yes No
Woodburning Stove:	Yes No
Central Air:	Yes No
Basement:
Number of Bathrooms:
Garage Type:
Garage Size:
Deck Size:
Porch Size:
Age of Roof (years):
Dog Breed(s):
Pool:	Yes No
Trampoline:	Yes No
If either pool or trampoline, is yard fenced?:	Yes No
Auto Information
Drivers - Fill in the needed information then click the "Add Driver" button to record driver.
Name:
Date of Birth:
Social Security Number:
Driver’s License Number:
Gender:	Male Female
Marital Status:	Married Single
	<- Driver info will be recorded here.
Vehicles - Fill in the needed information then click the "Add Vehicle" button to record vehicle.
Year:
Make:
Model:
VIN:
Main Driver:
Usage:	Pleasure Commute
	<- Vehicle info will be recorded here.
For All Vehicles
Current Limits of Liability:
Current Deductible:

Untitled Document

© 2013 Lighthouse Insurance Agency, LLC.
8213 Wicker Avenue, St. John, IN 46373, USA - (219) 365-0066 Phone - (219) 365-6529 Fax
email