Glenn Kaplan Agency
 
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Insured Name:  
Address:
City/State/Zipcode:
Phone Number:  
 Email:
SSN:
Residence Type:
Year Built:
Construction Type:
Is your home within 5 miles of a fire station:
Is your home within 1000 feet of a fire hydrant:
Alarm System:
Have you had any claims on any homes owned in last 5 years?
If yes please give a brief description of claim below.
Dwelling Coverage Amount:
Other Structures:
Personal Property:
Scheduled personal property:
(if yes please state dollar amount)
Additional Living Expenses:
Liability:
If Other enter the liability amount:
Medical payments:
Deductible:
Additional Information:

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Glenn Kaplan Agency
1531 Union Lake Road
Commerce Township, MI 48382
248-366-1000
kaplang@nationwide.com