Joseph Miratsky :: Auto / Home Insurance Quotes

COMPLIMENTARY AUTOMOBILE/HOMEOWNERS INSURANCE QUOTE FOR DRIVERS RESIDING IN ARIZONA AND/OR PROPERTIES LOCATED IN ARIZONA

REQUEST A FREE NO OBLIGATION QUOTE

Most Insurance Companies offer a discount on both the Automobile & Homeowners Insurance policy if purchased by same Insured. If applicable, I encourage you to complete both the Automobile and Homeowners section of this form.

I am interested in a quote for (check all that apply):
Automobile Golf Cart Motorcycle Recreational Vehicles
Homeowners Renter Rental Property (Landlord) Umbrella

Are you currently an Arizona Resident? Yes No
If you answered No, do you plan to become a resident of Arizona and if so when?

AUTOMOBILE INSURANCE
DRIVER ONE

Name:	Home Phone:	Email Address:
Occupation:	Cell Phone:

Marital Status - Choose One:
     If Divorced - Do you have child custody?
     If applicable, are you related to Driver Two and if so how?
Have you attended any safe drivers school? Yes No
     If Yes When?
     Will you be filing a SR-22 form? Yes No
     If yes state the reason(s) why:

DRIVER TWO (if applicable):
Name:
Are you Driver One’s spouse? Yes No (If NOT married please go to next question.)
Marital Status - Choose One:
     If Divorced - Do you have child custody?
Have you attended any safe drivers school? Yes No
     If Yes When?
     Will you be filing a SR-22 form? Yes No
     If yes state the reason(s) why:

ADDITIONAL DRIVERS (if applicable):
Will there be any additional drivers in or outside the household?
Is so please list full names and how are they related to you:

To Complete Your Quote:

Please email, fax or mail me your Auto Insurance Policy Declaration page(s) so I can generate a same coverage to coverage quote.

In addition, the insurers I represent require the insured’s age, education, occupation, drivers license # and preferably the insured’s social security number. Please call with this information.

Joe Miratsky
Office & Cell :: 480-279-3765
Private Fax (24/7) :: 480-279-3764
Email :: joe@miratsky.net
Mail :: 4714 S. Star Canyon Dr., Gilbert, AZ 85297

HOMEOWNERS INSURANCE and/or RENTAL PROPERTY INSURANCE

Name:	Home Phone:	Email Address:
Occupation:	Cell Phone:

Marital Status - Choose One:

Is this house being used or will it be used as a Rental property? Yes No

If you would like a quote on both a Homeowners and Rental property, please complete this form twice.
Year house was built? Sq Ft?
If you are in the process of purchasing this house, please enter the houses:
Address: City: State: Zip:

Purchase Price: Expected closing date:

Total Mortgage(s) on property (approx):

If you currently reside at the house or the house is a rental for which you already own, please enter the houses:
Address: City: State: Zip:

Do you have any fireplaces? Yes No
     If Yes - How many? Is it Gas or Wood?
Is your home heated by gas or electric?
Do you have smoke detectors in all your rooms? Yes No
Do you have motion detectors in your house? Yes No
Do you have any type or burglary alarm system? Yes No
Do you run any type of business from your house? (day care, home office, etc.) Yes No

What is the size of the lot your home sits on (1/4, 1/2, 3/4, 1 Acres etc.)?
Do you have any pets? Yes No
What type and where is it kept?
Do you have any livestock and/or horses on the property? Yes No
What type and where are they kept?

Do you have a swimming pool? Yes No
     Is it above ground? Yes No
     Does it have a diving board or waterslide? Yes No
     Max depth in feet?
     Do you have your pool fenced in? Yes No
     If so what type of fence and height?
Does your backyard lot line have a wall built on it? Yes No If so, wall height?
Do you have a Trampoline on your premises? Yes No

Do you have a detached structure? Yes No
     If so do you have a wood burning heating appliance in that structure? Yes No

If you haven't lived at the current address for at least 3 years, enter your previous address:
Address: City: State: Zip:

1, 2 or 3 level house? Basement? Yes No
How many bathrooms? Are they are 1/2, 3/4, or full?
Is your garage detached? Yes No How many car garage?
Is your garage attached? Yes No How many car garage?
Do you have tile or asphalt or other kind of roof?
Construction type (wood frame, block, brick, etc.):
Heating system (gas, electric, etc.):

Please disclose any renovations in detail completed on house since you owned it plus any other information that you believe will be helpful:

Where did you find out about me? If it was through a group, please name the group.

To Complete Your Quote:

Please email, fax or mail me your Home Owner's Insurance Policy Declaration page(s) so I can generate a same coverage to coverage quote.

In addition, the insurers I represent require the insured’s age, education, occupation, drivers license # and preferably the insured’s social security number. Please call with this information.

Joe Miratsky
Office & Cell :: 480-279-3765
Private Fax (24/7) :: 480-279-3764
Email :: joe@miratsky.net
Mail :: 4714 S. Star Canyon Dr., Gilbert, AZ 85297