283 S. Zeeb Rd., Suite F
Ann Arbor, MI 48103
Phone: (734) 213-0880
Fax: (734) 213-0974
   
2140 Grand River Annex
Brighton, MI 48114
Phone: (810) 231-8008
   
For 24-hour emergency claim service, call
(800) 435-7764
email:
tkantola@farmersagent.com
HOURS:
Monday through Thursday
9 a.m. to 6:00 p.m.
Friday 9a.m. to 5:00 p.m.
File a claim or check your claim status on-line at www.farmers.com

Name 
Address 
City 
State      ZIP 
Phone
E-mail 

Age  
  Male   Female
 Nicotine   Non-nicotine
Height   Weight  

Face Amount   

Years of Insurance
  5 Years
 10 Years
 20 Years
 30 Years
Type of Life Insurance
 Term Life
 Whole Life
 Universal Life