Holly Kornachuk 
                 15 Years of Experience

 
Auto Insurance
Roadside Assistance
Home Owners
Protector plus Home Package
Renters Insurance
Condominium
Personal Umbrella
Landlord Insurance
Life Insurance
Annuity
Business
Artisan Contractor
Restaurant
Health
Disability
IRAs
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Retirement Info
File Claims
 
Complimentary Quote for
Property / Life / Health / Disability
Insurance

General Information (*Required field)

Privacy Statement: Holly Kornachuk will not sell or rent your non-public information to anyone.

*Your Name
Title
Business/Organization
*Street address
*City
*State/Province
*Zip/Postal code
*Daytime phone
Evening phone
Fax
E-mail
      
Date of Birth
     
Select the type of insurance coverage desired or go to
[ Submit Information ]
[ General Info ] [ Property ] [ Life ] [ Health ] [Disability ]

Property Insurance (Home, Condo, Farm, Renters or Dwelling)

Not sure what to enter, please call me to discuss

Type of Insurance
Property address
(if different than above)
Square Footage
Type of Construction
Year of Construction
Do you have a Monitored Alarm System?. Yes  No
Dwelling amount of coverage desired?

Personal Liability limit
Have there been any paid claims in past 3 years Yes No
Deductible
Condo or Renters insurance: What is personal property value
   
Non-Smoker? Yes  No
Current Policy Expiration
Current Policy Rate
   
Select the type of insurance coverage desired or go to
[ Submit Information ]
[ General Info ] [ Property ] [ Life ] [ Health ] [Disability ]

Life Insurance

Not sure what to enter, please call me to discuss

Do You Smoke? Yes  No
List Chronic Health Problems
Amount of Insurance Desired
    
Currently Insured? Yes  No
Current Policy Expiration
Current Policy Rate
   
Select the type of insurance coverage desired or go to
[ Submit Information ]
[ General Info ] [ Property ] [ Life ] [ Health ] [Disability ]

Health Insurance

Not sure what to enter, please call me to discuss

Do You Smoke? Yes  No
List Medications You Currently Take
Height
Weight
Any Children? Yes No
If Children, List Ages
Self Employed? Yes No
   
Amount of Insurance Desired
    
Currently Insured? Yes  No
Current Policy Expiration
Current Policy Rate
   
Select the type of insurance coverage desired or go to
[ Submit Information ]
[ General Info ] [ Property ] [ Life ] [ Health ] [Disability ]

Disability Insurance

Not sure what to enter, please call me to discuss

Occupation?
Monthly Salary?
   
   
Amount of Insurance Desired
    
Currently Insured? Yes  No
Current Policy Expiration
Current Policy Rate
   
Select the type of insurance coverage desired or go to
[ Submit Information ]
[ General Info ] [ Property ] [ Life ] [ Health ] [Disability ]

Final Data Entry & Submittal of Information

Where did you hear about us?
 
Any additional questions or comments?
 
Once you have completed the above form,
please hit 'Submit Information' ONLY once.
Thank you.

 

 

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Call, , or use our convenient on line Request Info form for additional information about Holly Kornachuk products and services offered.

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Holly Kornachuk, Farmers Insurance
 21800 Haggerty Rd., Suite 109, Northville, MI
Phone: 248.468.0222 Fax: 248.468.2999

Hours: Monday - Friday 8:00 AM to 5:00 PM

 

 

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