Agency Home and Auto Quote Form Which of these types of policies do you need quotations for? Home Renters Auto Life Personal Umbrella Specialty (Boat, ATV, RV, Moto) Dwelling Fire/ Rentals Commercial or Business First Name*Last Name*What is your mailing address?* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* Date Format: MM slash DD slash YYYY Occupation?*What is your highest education level?*Didn't Finish High SchoolHigh SchoolSome Collage2 year Degree/Vocational Training4 year DegreeMastersDoctorateCurrent Marital Status?*MarriedSingleSingle with childrenDomestic PartneredSeparatedWidowedDivorcedSpouses Name First Last Spouses Date Of Birth Date Format: MM slash DD slash YYYY Spouses Occupation?Spouses highest level of Education?Didn't finish High SchoolHigh School2 year Degree/Vocational Training4 year DegreeMasters DegreeDoctorateHome Phone NumberCell Phone NumberEmail Address to insure-if different from mailing address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you the deeded owner of this property?*YesNoOther-PROVIDE DETAILS BELOWOccupancy:*PrimarySecondarySeasonalVacantTenantOther-PROVIDE DETAILS BELOWMonth and year of home purchase?Previous address? If less then 4 years at current addressIs this home for sale or are there any plans for listing in the nest 12 months?*YesNoOther-PROVIDE DETAILS BELOWWhat year was your home built?*How many family units does your home have?*How many Stories is the Home?*11.522.533.54Bi level/ Tri levelLiving area square footage?*Don't include basement, attic or garageWhat type of Roof does your home have?*HipGableFlatCombinationOtherWhat year was your roof last replaced?*How many layers of single is on your home?*What is the primary foundation type?*Basement unfinishedBasement Partial FinishedBasement 100% finishedSlabCrawl SpaceWhat percent of the basement is finished?What is the exterior of your home made out of?*How many bathrooms does your home have?*What is the Bathroom quality?*BasicBuilders GradeSemi-CustomCustomDesignerLuxuryWhat is the Kitchen quality?*BasicBuilders GradeSemi-CustomCustomDesignerLuxuryDoes the Home have a Garage?*01 Car2 Car3 Car4 Car5 Car or MoreBuilt inBasementCarportCombination-provide details in recapDo you have a mortgage? Does escrow pay?*What is the name of your mortgage company?Who currently insures your home?*What is your renewal date?How many years have you had your current policy?*Current Coverage A Limit?*What is your current All-Peril Deductible? Wind/Hail?*Does your policy currently provide coverage for? Water Backup Earthquake Personal Injury Coverage A Extended Limits Ordinance and Law Allrisk coverage on personal property What is your target premium cost? OPTIONALWhat is the heating type?*Central Natural GasCentral ElectricCentral PropaneNon centralizedOther-provide details in recapWhen was the Last Time you HVAC was updated?Is your heating system centralized and thermostatically controlled?*YesNoUnsure-must verifyWhat type of wiring does the home have? Examples: Copper, Aluminum, Knob and Tube:What type of electrical system does your home have?*Circuit breaker more than 100 AMPCircuit breaker less than 100 AMPFuse more than 100 AMPFuse less than 100 AMPOther/ combination-provide details in recapDo you have any?* Trampolines Pool Farming Equipment Home Business Livestock Farming structures Solar Panels Smart Home None What is the total number of household members? 1 2 3 4 5 6 7 8 9 or more Does your home have any of the following? Fireplace Wood Burning Fireplace Gas Burning Stand alone wood or coal burning stove Wood Burning Stove Insert Other--PROVIDE DETAILS IN RECAP Does you home have attached structures? Patio Deck Porch Other Description of Attached Structures:Do you or any household member own or care for any pets or animals? List type and breed:*Do any of these animals have a bite history or have caused property damage?*Does your home have ANY galvanized, Polybutylene or PEX plumbing?*NoYesUnsureProvide information about plumbing condition:*Does your home have any underground FUEL storage tanks?*NoYesUnsureAny un-repaired damage or defects present for the dwelling?*NoYesIs this home modular or manufactured construction?*NoYesDo you currently have replacment cost coverage on your roof*NoYesUnsureDo you have a monitored Alarm System?*NoYes-Central or DirectLocal onlyDescription of other structures:Do ANY other structures have solid fuel heating?*YesNoUnsureHave you had any claims in the past 6 years?*Has your home had any major renovations in the last 10 years?*Relevant home details: How many Vehicles do you currently insure?*12345More then 6--Year Make and Model of Vehicle 1*Ensure vehicle is registered to named insuredIs Vehicle 1 Vehicle Financed?*Yes- OwnedYes- FinancedYes -LeasedNoVehicle 1 year of purchase and miles driven?*Vehicle 1 Comp/ Coll deductible?*Year Make and Model of Vehicle 2Ensure vehicle is registered to named insuredIs Vehicle 2 Financed?Yes- OwnedYes-FinancedYes-LeasedNoVehicle 2 year of purchase and miles driven?Vehicle 2 Comp/ Coll deductible?Year Make and Model of Vehicle 3Ensure vehicle is registered to named insuredIs Vehicle 3 Financed?Yes - OwnedYes - FinancedYes- LeasedNoVehicle 3 year of purchase and miles driven?Vehicle 3 Comp/ Coll deductible?Year Make and Model of Vehicle 4Ensure vehicle is registered to named insuredIs Vehicle 4 Financed?Yes - OwnedYes - FinancedYes - OwnedNoVehicle 4 year of purchase and miles driven?Vehicle 4 Comp/ Coll deductible?Year Make and Model of Vehicle 5Ensure vehicle is registered to named insuredIs Vehicle 5 Financed?Yes - OwnedYes - FinancedYes- LeasedNoVehicle 5 year of purchase and miles driven?Vehicle 5 Comp/ Coll deductible?If vehicles are financed indicate the name of the finance company here:Unrepaired damage on any above listed vehicles?Are any vehicles described above garaged away from your residence?Has any operator had any tickets, suspension or accidents in the past 5 years?*Are there any additional household members age 15 or older or any regular vehicle operators?Who is your current Auto Insurer?What are you current Bodily Injury Limits?25/5050/100100/300250/500500/500How many years have you been with your current company?*Do you paid your premium in full or monthly? How much do you pay?When do you make your next payment?Are ANY of your vehicles used for business or commercial purposes? Including Ride or Car Sharing*NoYesAre all vehicles registered to a named insured?*NoYesUnsureDo any vehicles have a salvage or rebuilt title?*NoYesUnsureCurrent Personal Umbrella Limit$1 Million$2 Million$3 MillionOtherHave any named insured been convicted of a type of felony in the last 10 years?*NoYesUnsureCan we follow up with on your next renewal with updated quotes?YesNoCan we text you on the provided cell number?YesNoHow did you hear about us?*Where you referred? By Whom?Could we provide you a quote for life insurance? If so provide relevant details below:Requested coverage C Limit for renters?Type of Dwelling?Do you have any pets?Current Height and Weight?Do you use tobacco?Describe specialty lines:Vehicle type? Year of Purchase? Current Value? Horsepower? length? Garaged location?Applicable details of rental properties:Property Address? Who has Ownership? Current coverage? Age of home and roof? Dogs? Lease term?FINAL RECAP NOTATIONS*Insurance AgentBrandonCatherineEmailThis field is for validation purposes and should be left unchanged.
