Personal Insurance Proposal

How did you hear about AIC?*
Name*
First Last
Current Mailing Address*
Street Address Address Line 2 City State ZIP Code
Home Address*
Same as current mailing address

Street Address Address Line 2 City State ZIP Code
Personal Information for each household member:
Household Member #1 Name*
First Last
Household Member #1 Date of birth*
Month
Day
Year
Household Member #1 Driver License Number
Household Member #1 Cell Phone
Household Member #1 Home Phone
Household Member #1 Work Phone
Household Member #1 Email*
Household Member #1 Employer and Occupation
Household Member #1 Social Security Number
Add a second household member*
- Yes
- No
Personal Information for Second Household Member:
Household Member #2
First Last
Household Member #2 Date of birth
Month
Day
Year
Household Member #2 Driver License Number
Household Member #2 Cell Phone
Household Member #2 Home Phone
Household Member #2 Work Phone
Household Member #2 Email
Household Member #2 Employer and Occupation
Household Member #2 Social Security Number
Add a third household member*
- Yes
- No
Personal Information for Third Household Member:
Household Member Name #3
First Last
Household Member Date of birth #3
Month
Day
Year
Household Member #3 Driver License Number
Household Member #3 Cell Phone
Household Member #3 Home Phone
Household Member #3 Work Phone
Household Member #3 Email
Household Member #3 Employer and Occupation
Household Member #3 Social Security Number
Add a fourth household member*
- Yes
- No
Personal Information for Fourth Household Member:
Household Member Name #4
First Last
Household Member Date of birth #4
Month
Day
Year
Household Member #4 Driver License Number
Household Member #4 Cell Phone
Household Member #4 Home Phone
Household Member #4 Work Phone
Household Member #4 Email
Household Member #4 Employer and Occupation
Household Member #4 Social Security Number
Add additional household members?*
- Yes
- No
Personal Information for any additional Household Members:
Please provide the names and birth dates and SSN for each additional household member.
Additional Household Questions:
Do you own any seasonal homes or rental properties*
- Yes
- No
Do you have a pool and/or trampoline on your property?*
- Yes
- No
if yes, is the yard fenced?*
- Yes
- No
Do you own any dogs or other animals?*
- Yes
- No
if so, what breed? Any bite history?*
Why are you looking to switch insurance companies?*
Copies of your current insurance declarations for all insurance policies.
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Contact Information

Office Hours - 7am to 5pm
Phone Hours - 8am to 4pm
Monday Thru Friday
7275 Bronson St. S.E.
Ada, MI 49301
Toll Free: (888) 695-9777
Phone: (616) 676-4000
Fax: (616) 676-4010

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Personal Insurance Proposal

Personal Information for each household member:

Personal Information for Second Household Member:

Personal Information for Third Household Member:

Personal Information for Fourth Household Member:

Personal Information for any additional Household Members:

Additional Household Questions:

Contact Information

Community Involvement

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Personal Insurance Proposal

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