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~Request Insurance Quote~
Personal Insurance Questionnaire
If you are human, leave this field blank.
Insured Contact info
This is the contact info we'll need for the primary individual insured.
Your Name
*
Your Phone
*
Email Address
*
Physical Address
*
Mailing Address (if different than physical)
What kind insurance would you like us to quote?
Homeowners
Auto
RV
Life Insurance
Other
Disclosure: In order to provide an accurate quote, we will need private personal information. Some of this information will be confirmed through other sources such as consumer credit agencies. All of the information you share with us is held in strict confidence and will only be used to obtain quotes from various insurance companies. Your personal information will never be shared with anyone outside our agency or the insurance companies we represent.
*
"YES, I have read and understand the above disclosure. I consent to the use of my private personal information."
Would you like to upload a copy of your current coverage?
You're welcome to upload a copy of any coverage you would like us to quote or you can complete our questionnaire. The questionnaire can take 10-20 minutes to complete depending on how much info you have to input. You can also call us and we'll fill this out over the phone with you. (877) 747-1982
Upload?
*
YES
NO - Complete questionnaire (10 minutes)
Personal Information
Name
*
Date of Birth
*
Social Security Number#
*
STRICTLY CONFIDENTIAL – This allows us to obtain consumer reports to get a fully qualified quote for you.
Marital Status
*
Single
Married
Divorced
Widowed
What level of education do you have?
*
High School/GED
Completed some college or are currently enrolled
Associates Degree
Bachelors Degree
Other
Other
Notes/Comments
Add
Remove
HOMEOWNERS Section
Home Type
Home
Condo
Mobile Home
Apartment
Do you own your home?
Own
Rent
Other
Other
How long have you been at this address?
Year of construction
Approximate square footage of the home
Have you updated anything since it was built? Please type in the year.
Roof
Roof
Wiring
Wiring
Plumbing
Plumbing
Heat/AC
Heat/AC
Exterior Paint
Exterior Paint
Type of Construction
Frame
Masonry
Metal
Manufactured Home
Other
Other
Type of Roof
Asphalt Shingle
Metal
Tile
Other
Other
Name of Fire Department and how many miles away are you?
How many feet away are you from a fire hydrant?
Protective Devices
Smoke Detectors
Deadbolt Locks
Fire Extingusher
Central Station Alarm (Reports to a company)
Local Alarm (In home only)
Do you have any pets? (dogs, cats, horses, etc.)
If dog, what type and ever bitten anyone?
Do you have any high value items such as jewelry, art, firearms, collectibles, etc?
Most companies have a default limit of insurance for these items between $2,500 and $5,000. Let us know if you have more than that?
Do you have any recreational vehicles such as ATV's, jet-ski's, motorcycles, etc?
If so, please describe.
Check any that apply (We'll contact you for additiona info)
Is home is vacant more than 180 days per year?
Do you have a Woodstove or Fireplace?
Do you have a trapoline or skateboard ramp?
Do you have a pool?
Have you had any claims in the last 5 years? (Please describe)
Have you had any claims in the last 5 years? (Please describe)
Do you have a home business?
Do you have a home business?
Are you interested in any of the following coverages?
Flood Insurance
Earthquake Insurance
Other
Other
What property deductible would you like?
$500
$1,000
$2,500
$5,000
Other
Other
What liability limit would you like?
$100,000
$250,000
$300,000
$500,000
$1,000,000
Other
Other
Notes/Comments
AUTO Section
Liability Limit
$15,000
$50,000
$100,000
$250,000
$500,000
$1,000,000
Other
Other
Medical Payments Limit
$1,000
$5,000
$10,000
Check any that apply. (We'll contact you for more info if needed)
Accidents in 3 years?
Accidents in 3 years?
Any citations in 3 years?
Any citations in 3 years?
Other drivers in the home not insured?
Other drivers in the home not insured?
Other
Other
Check any that apply. (We'll contact you for more info if needed)
All vehicles registered in the same state?
Any vehicles used for delievery?
Any vehicles used for delievery?
Is any vehicle driven over 7,000 miles/year?
Is any vehicle driven over 7,000 miles/year?
Are all vehicles parked at home address?
Are all vehicles parked at home address?
Notes/Comments
Driver Info
Please add additional drivers by using the "Add" button at the bottom.
Driver's Name
Date of Birth
License Number#
Check all that apply
Good Student 'B' or better?
Driver Training certificate?
Other
Other
Notes/Comments
Add another driver
Remove
Vehicle Info
Please add additional vehicles by using the "Add" button at the bottom.
Year
Make
Model
VIN (Vehicle Identification Number)
Check all that apply
Do you want Comprehencive or Collision Coverage?
Vehicle have anti-theft device?
Is vehicle used for delivery?
Notes/Comments
Add another vehicle
Remove
RV
Please provide the Year, Make, Model, and VIN of your RV.
LIFE INSURANCE Section
Please provide some information on what kind of Life insurance solution you're looking for.
OTHER
Please provide some information on the other insurance you would like us to review such as a Personal Umbrella Policy and we'll contact you.
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