What Insurance Do You Need Quoted?
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| Applicant Information | |
|---|---|
| First Name: | |
| Last Name: | |
| DOB: | |
| Resident Address: | |
| Address Line 2: | |
| Resident City: | |
| Resident Zip: | |
| Occupation: | |
| Highest Education: | |
| Marital Status: | |
| Spouse First Name: | |
| Spouse Last Name: | |
| Spouse DOB: | |
| Spouse Occupation: | |
| Spouse Highest Education: | |
| Vehicle | |
|---|---|
| How many vehicles would you like quoted? | |
| Vehicle Coverage Questionnaire | |
|---|---|
| Who is your current auto insurance carrier? | |
| How long have you been with your current insurance carrier? | |
| What are your current liability limits? | |
| What are your current uninsured liability limits? | |
| What is your current medical limit? | |
| Would you like roadside assistance included in your quote? | |
| Would you consider paying your premium in full if it provides a discount? | |
| Would you consider a usage-based driving program if it could lower your premium? | |
| Year: | |
Make: |
|
| VIN: | |
| Year Purchased: | |
| Vehicle Use: | |
| Annual Miles: | |
| Ownership: | |
| Desired Coverage: | |
| Collision Deductible: | |
| Comprehensive Deductible: | |
| Glass Deductible: | |
| Rental Car Benefit: | |
| Roadside Coverage: | |
| Driver Information | |
|---|---|
| How many drivers will be on your policy? | |
| First Name: | |
| Last Name: | |
| DOB: | |
| Gender: | |
| Driver's License Number: | |
| Driver's License State: | |
| Relation: | |
| SR 22 Needed: | |
| Commercial Auto Count | |
|---|---|
| How many vehicles do you insure? | |
| Commercial Driver | |
|---|---|
| How many drivers will be on your commercial policy? | |
| Commercial Auto Questionnaire | |
|---|---|
| Would you consider a usage-based driving program if it could lower your premium? | |
| Do you expect your insurance to pay towing or roadside assistance expense? | |
| If your windshield needed to be replaced today, how much would you want to pay? | |
| What is your preferred comp and collision deductibles? | |
| Would you be interested in going to higher deductibles to reduce premium? | |
| Would you consider paying your premium in full if it provides a discount? | |
| Year: | |
| Make: | |
| VIN: | |
| Year Purchased: | |
| Annual Miles: | |
| Ownership: | |
| Desired Coverage: | |
| Collision Deductible: | |
| Comprehensive Deductible: | |
| Glass Deductible: | |
| Rental Car Benefit: | |
| Roadside Coverage: | |
| Liability Limits: | |
| Uninsured Liability Limits: | |
| Medical Limits: | |
| Uninsured Property Coverage: |
| First Name: | |
| Last Name: | |
| DOB: | |
| Gender: | |
| Drivers License: | |
| SR 22 Needed: |
| Homeowners Questionnaire | |
|---|---|
| What type of home do you own? | |
| What month and year did you purchase your home? | |
| Who is your current property insurance carrier? | |
| Is your home in a HOA? | |
| How many dogs? | |
| Year Built: | |
| Foundation Type: | |
| Year Roof Replaced: | |
| Roof Material: | |
| Impact Resistant: | |
| Garage: | |
| Garage Sizes: | |
| Value of detached structures (shed, barn, greenhouse, fencing,etc): | |
| Kitchen grade: | |
| Bathroom grade: | |
| Fireplace count: | |
| What month and year did you purchase your home? | |
| Who is your current property insurance carrier? | |
| Is your home in a HOA? | |
| How many dogs? | |
| Year Built: | |
| Kitchen & bathroom grade: | |
| Floor Located: | |
| What month and year did you purchase your home? | |
| Who is your current property insurance carrier? | |
| Is your home in a HOA? | |
| How many dogs? | |
| Year Built: | |
| Kitchen & bathroom grade: | |
| Basement: | |
| % Basement finished: | |
| # Of Units: | |
| End/Middle Unit: | |
| What month and year did you purchase your home? | |
| Who is your current property insurance carrier? | |
| Is your home in a HOA? | |
| How many dogs? | |
| Year Built: | |
| Number of units: | |
| Kitchen & bathroom grade: | |
| What month and year did you purchase your home? | |
| Who is your current property insurance carrier? | |
| How many dogs? | |
| Model Year: | |
| Width: | |
| Length: | |
| Coverage amount needed: | |
| Property Information: | |
|---|---|
| How many properties do you insure? | |
| Type of property? |
| Renters Questionnaire | |
|---|---|
| How many dogs? | |
| Unit Sq Ft: | |
| Type of residence: | |
| Personal Property | |
| Motorcycle Information: | |
|---|---|
| How many motorcycles do you insure? | |
| Motorcycle Coverage Questionnaire | |
|---|---|
| Do you have a motorcycle endorsement on their license? | |
| Have you completed a safety course? | |
| Year: | |
| Make: | |
| Model: | |
| CC's: | |
| Purchase Price: | |
| Current Value: | |
| Who rides this motorcycle? | |
| Desired Coverage: | |
| Collision Deductible: | |
| Comprehensive Deductible: | |
| Glass Deductible: | |
| Roadside Coverage: | |
| Custom Equipment Value: | |
| Liability Limits: | |
| Uninsured Liability Limits: | |
| Medical Limits: | |
| Uninsured Property Coverage: | |
| RV Count: | |
|---|---|
| How many RV's do you insure? | |
| RV Coverage Questionnaire | |
|---|---|
| Would you consider a usage-based driving program if it could lower your premium? | |
| Would you like roadside assistance included in your quote? | |
| If your windshield needed to be replaced today, how much would you want to pay? | |
| What is your preferred comp and collision deductibles? | |
| Would you be interested in going to higher deductibles to reduce premium? | |
| What would best describe your financial situation? | |
| Would you consider paying your premium in full if it provides a discount? | |
| Year: | |
| Make: | |
| Model: | |
| Year Purchased: | |
| Lenght Use: | |
| Purchase Price: | |
| Current Value: | |
| Ownership: | |
| Desired Coverage: | |
| Collision Deductible: | |
| Comprehensive Deductible: | |
| Glass Deductible: | |
| Roadside Coverage: | |
| Liability Limits: | |
| Uninsured Liability Limits: | |
| Medical Limits: | |
| Uninsured Property Coverage: |
| ATV/UTV Count: | |
|---|---|
| How many atv's do you insure? | |
| Year: | |
| Make: | |
| Model: | |
| CC‘s: | |
| Purchase Price: | |
| Current Value: | |
| Desired Coverage: |
| Personal Umbrella Questionnaire | |
|---|---|
| What limits of liability do you need? | |
| How many properties do you own? | |
| How many vehicles do you own? | |
| How many drivers do you insure? | |
| How many drivers under the age of 25? | |
| How many watercraft do you own? | |
| General Liability Questionnaire | |
|---|---|
| Business name: | |
| Is your business address different than your residential address? | |
| Business physical address: | |
| Business physical city, st, zip: | |
| Do you lease or own your business location? | |
| Type of business: | |
| Brief Description Of Operations: |
|
| How is the business structured: | |
| Years of industry experiences: | |
| What year did the business begin? | |
| Business website: | |
| Number of full time employees: | |
| Number of part time employees: | |
| Do you use sub-contractors? | |
| Annual sales: | |
| Annual payroll (not including sub-contractors, clerical, or owner): | |
| Annual clerical payroll: | |
| What percent of annual sales is paid to sub-contractors: | |
| Building construction type: | |
| Total square footage of building: | |
| Total square footage occupied: | |
| Year built: | |
| Number of stories: | |
| Roof replaced: | |
| 100% sprinklered: | |
| How much business property coverage do you need? | |
| How much tool coverage do you need? | |
| How much equipment coverage do you need? | |
| Do you do anything with new construction or track homes? | |
| How much liability coverage do you need? | |
| Current General Liability Carrier: | |
| Number of claims in the last 5 years: | |
| Do you need a workers compensation policy? | |
| Current Workers Comp Carrier: | |
| Commercial Umbrella Questionnaire | |
|---|---|
| What limits of liability do you need? | |
| How many commerical properties do you own? | |
| How many commerical vehicles do you own? | |
| How many commerical drivers do you insure? | |
| How many commerical drivers under the age of 25? | |
| How many commerical watercraft do you own? | |
| Congratulations! We have what we need to prepare your quotes. | |
|---|---|
| What email would you like us to send your results? | |
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Have your current declaration pages?
Uploading your declaration pages helps us make sure our quotes are accurate and typically leads to a much faster response. It is not required, but we appreciate it! PDF, JPG or PNG. Up to 5 files, 7 MB total. |
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| Your information is never sold. We will only contact you regarding your insurance request. | |
| Thank You! |
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