Mickey Clayton Insurance


Please fill out as much information as you have so that your quote will be correct.

Contact Information
Street Address: 
Address (cont.): 
Zip/Postal Code: 
Work Phone: 
Home Phone: 

Home Information
Location of Dwelling
  Street Address: 
Zip/Postal Code: 
Present Policy Expiration Date:  (MM/DD/YYYY)
Present Homeowner Premium: $

Dwelling Information
  Do you own or rent?  Own    Rent
Type of residence:  House    Condo    Apartment
Type of construction:  Frame    Masonry   
Fire Protection?  Yes    No
List any improvements
to the inside of dwelling: 

If you own a house, please list:
  The present dwelling coverage: $
The square footage: 
The year of construction:  (MM/DD/YYYY)
If over 30 years old, any updates? 

If you own or rent a condominium, please list:
  The amount of personal property: $
The number of units per building: 

Coverage Information
Are you interested in increased coverage for:
  Jewelry, Fur, Silver or Fine Art, Guns, Business Property?  Yes    No
Liability and medical payments?  Yes    No

Does your dwelling have:
  Smoke Alarms?  Yes    No
Fire Alarm?  Yes    No
Dead-bolt locks on all exterior doors?  Yes    No
List any other alarm systems: 

Does your dwelling have:
  Any claims in the last 3 years?  Yes    No
If yes, please explain: 

Quoting available for AZ only