Phone: 606-474-5128
Fax: 606-474-5001
Email: info@millerins.net
Hours: Mon-Fri 9-5pm, Sat: 9-12pm
210 South Carol Malone Blvd
Grayson, KY 41143

Make a Payment
File a Claim
Service
Get a Quote

Home Insurance

Personal Information
Name
Date of Birth
Spouse Name
Spouse Date of Birth
Address
City
State
Zip Code
Comments
Day Phone
Evening Phone
Email Address
Occupation
How Long At Current Job?
Current Homeowners Insurance Information
Company Name (not agency)
Policy Expiration Date
Premium Amount $
Amount Insured For $
Policy Type
Primary Secondary
Term
6 Months 1 Year Other
If Other, Specify
Home Information
How Long At Present Address
Year Home Was Built
Sq. Footage
# of Claims In Last 3 Years
Servicing Fire Department
Miles to Dire Department
Feet to Fire Hydrant
Structure Information
Type
Construction
Roof
Foundation
Garage
Features
Bathrooms
Basement
Deck/Porch/Patio
Fireplaces
Heating System
Central Air
Central Vac
Security Alarm
Fire Alarm
Smoke Detector
Permission to Obtain Consumer Reports
To provide an accurate quote, we have asked you a series of questions some of which we will confirm through consumer reports, which may include credit, motor vehicle and loss information reports. This information will be available to our companies with whom we will obtain your quote.
Is it O.K. to continue
Yes No
Fraud Statement
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.
I have read the above Fraud Statement
Yes No

Website Builder