BThompson

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

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First Name*
Last Name*
What is your mailing address?*
Street Address City State ZIP Code
Date of Birth*
MM slash DD slash YYYY
Occupation?*
What is your highest education level?*
Current Marital Status?*
Spouses Name
First Last
Spouses Date Of Birth
MM slash DD slash YYYY
Spouses Occupation?
Spouses highest level of Education?
Home Phone Number
Cell Phone Number
Email

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How many Vehicles do you currently insure?*
Year Make and Model of Vehicle 1*

Ensure vehicle is registered to named insured
Is Vehicle 1 Vehicle Financed?*
Vehicle 1 year of purchase and miles driven?*
Vehicle 1 Comp/ Coll deductible?*
Year Make and Model of Vehicle 2

Ensure vehicle is registered to named insured
Is Vehicle 2 Financed?
Vehicle 2 year of purchase and miles driven?
Vehicle 2 Comp/ Coll deductible?
Year Make and Model of Vehicle 3

Ensure vehicle is registered to named insured
Is Vehicle 3 Financed?
Vehicle 3 year of purchase and miles driven?
Vehicle 3 Comp/ Coll deductible?
Year Make and Model of Vehicle 4

Ensure vehicle is registered to named insured
Is Vehicle 4 Financed?
Vehicle 4 year of purchase and miles driven?
Vehicle 4 Comp/ Coll deductible?
Year Make and Model of Vehicle 5

Ensure vehicle is registered to named insured
Is Vehicle 5 Financed?
Vehicle 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?
How 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*
Are all vehicles registered to a named insured?*
Do any vehicles have a salvage or rebuilt title?*
Current Personal Umbrella Limit
Have any named insured been convicted of a type of felony in the last 10 years?*
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Can we follow up with on your next renewal with updated quotes?
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Can we text you on the provided cell number?
How 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 Agent
Comments
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Brandon and his team are phenomenal to work with. They are very patient, and explain every part of the process with personal attention. ...

4 months ago

Anthony Carroll

Great customer service! I live out of state and have a rental property in Springfield. Liz always looks for the best policy and pricing when...

5 months ago

Maria S

Recently I had the pleasure of working with Liz Letterman, a personal lines agent of Millennium Brokers Ins., located in Springfield MO. Not only...

3 months ago

Debbie Harms

It was a very easy process to change from AARP to a company Brandon recommended for my Homeowners and Auto policies saving me a substantial...

Joe Bryant

I was referred by a friend to Millenium Brokers as it was time to shop for new insurance. I did not want to go...

Jennifer Napier

Agency Home and Auto Quote Form

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