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    Complete Online Quoting Form


    Which statement(s) best describes you now (check all that apply):

    Do you have a proposed closing date?

    What is proposed closing date?

    I’m interested in quotes for (check all that apply):

    We recommend quoting home/condo/renter’s WITH the auto to avoid losing major discounts!
    IMPORTANT — To qualify for an umbrella, we have to also insure all your autos too!
    We recommend having your primary home (and auto) quoted along with your rental home for most discounts.

    Personal Information

    Your full name (legal)

    Your phone number

    Your email address

    Your date of birth

    Your social security number (not required for quote but helps for accuracy)

    Your driver’s license state

    Your driver’s license number (not required for quote but helps for accuracy)

    Have you had any accidents or tickets the past 5 years?

    Please explain

    Do you need an SR-22 filing?

    Are you a driver for any motorcycle?

    How many years of riding experience do you have?

    How often do you ride during the season?

    What is your primary occupation? (possible discounts with some companies)

    What is your current marital status?

    Your spouse’s full name (legal)

    Your spouse’s date of birth

    Your spouse’s social security number (not required for quote but helps for accuracy)

    Your spouse’s driver’s license state

    Your spouse’s license number (not required for quote but helps for accuracy)

    Has your spouse had any accidents or tickets the past 5 years?

    Please explain

    Does your spouse need an SR-22 filing?

    Is spouse a driver for any motorcycle?

    How many years of riding experience do you have?

    How often does your spouse ride during the season?

    What is your spouse’s primary occupation? (possible discounts with some companies)

    NOTE: your spouse will be referred to as “co-applicant” throughout form.

    Co-applicant’s full name (legal)

    Co-applicant’s date of birth

    Co-applicant’s social security number (not required for quote but helps for accuracy)

    Co-applicant’s driver’s license state

    Co-applicant’s license number (not required for quote but helps for accuracy)

    Has co-applicant had any accidents or tickets the past 5 years?

    Please explain

    Does co-applicant need an SR-22 filing?

    Is co-applicant a driver for any motorcycle?

    How many years of riding experience do you have?

    How often does co-applicant ride during the season?

    What is co-applicant’s primary occupation? (possible discounts with some companies)

    Your current physical street address (where you live now)

    How long have you lived at this address?

    What was your previous permanent address?

    —–Homeowner’s Section—–

    Property Information

    Is this a new purchase or are we quoting your current home?

    What is the address of the property we’re quoting?

    When did you purchase this home?

    This residence is:

    Please explain

    What year was the home built?

    What is the finished square footage of this home? (do not include finished basement or attic)

    How many stories is the home? (do not include basement)

    How many full bathrooms are there?

    How many half bathrooms are there?

    How would you classify the quality level of the kitchen?
    builder’s grade | semi-custom | custom

    How would you classify the quality level of the bathroom(s)?
    builder’s grade | semi-custom | custom

    Is there a garage?

    What size is the attached garage?
    What size is the detached garage?

    Are there any other detached structures on the premises?

    Please provide more detail

    What is the exterior finish of the home? (check all that apply)

    What type of foundation does the home have? (check all that apply)

    Is basement finished?

    Is there a sump pump?

    Are there any auxiliary heat sources in the home? (check all that apply)

    How old (years) is the roof on the home?

    What is the roofing material?

    What type of central heating system is in the home?

    What is the age (years) of the heating system?

    What type of electrical service does this home have?

    Liability Information

    How many household residents? (any who would consider this their primary residence.)

    If you’d like to provide additional information (optional):

    Is there, or will there be, a trampoline?

    Is the trampoline netted?

    Is the trampoline within a fenced yard?

    Is there a swimming pool?

    The pool is:

    Check all that apply:

    Pets, animals or livestock. Check any box that applies to you.

    What breed(s) of dog(s) do you have?

    How many dogs do you have?
    What kind(s) of farm animals do you have?

    How many farm animals do you have?
    Please provide more detail about exotic animal(s)

    Is there any type of business operation in the home (ex. that generates higher than normal foot traffic)

    Please provide more detail

    Property Losses/Claims History Information

    In the past 5 years, have you filed any claims on any homeowner’s or renter’s policies?

    Please provide more detail

    Coverage Information

    The standard minimum homeowner’s deductible we usually quote is $1,000.

    Please quote me with a
    deductible.

    Please let us know if you’d be interested in, or would like more info about the following coverages

    What date would you like this policy to begin

    —–Condo-owner’s Section—–

    Property Information

    Is this a new purchase or are we quoting your current home?

    What is the address of the condo we’re quoting?

    When did you purchase this condo?

    This residence is:

    Please explain

    What year was the condo built?

    What is the finished square footage of this home? (do not include finished basement or attic)

    How many stories is the condo? (do not include basement)

    How many full bathrooms are there?

    How many half bathrooms are there?

    How would you classify the quality level of the kitchen?
    builder’s grade | semi-custom | custom

    How would you classify the quality level of the bathroom(s)?
    builder’s grade | semi-custom | custom

    Is there a garage?

    What size is the attached garage?
    What size is the detached garage?

    What type of foundation does the home have? (check all that apply)

    Is basement finished?

    Is there a sump pump?

    Are there any auxiliary heat sources in the home? (check all that apply)

    How old (years) is the roof on the home?

    What type of central heating system is in the home?

    What is the age (years) of the heating system?

    What type of electrical service does this home have?

    Liability Information

    How many household residents? (any who would consider this their primary residence.)

    If you’d like to provide additional information (optional):

    Is there, or will there be, a trampoline?

    Is the trampoline netted?

    Is the trampoline within a fenced yard?

    Is there a swimming pool?

    The pool is:

    Check all that apply:

    Pets, animals or livestock. Check any box that applies to you.

    What breed(s) of dog(s) do you have?

    How many dogs do you have?
    What kind(s) of farm animals do you have?

    How many farm animals do you have?
    Please provide more detail about exotic animal(s)

    Is there any type of business operation in the home (ex. that generates higher than normal foot traffic)

    Please provide more detail

    Property Losses/Claims History Information

    In the past 5 years, have you filed any claims on any homeowner’s or renter’s policies?

    Please provide more detail

    Coverage Information

    The standard condo-owner’s deductible we usually quote is $500.

    Please quote me with a
    deductible.

    Please let us know if you’d be interested in, or would like more info about the following coverages

    What date would you like this policy to begin?


    —–Rental Section—–

    Property Information

    How many rental properties do you own? (max. 2 for this form)

    Rental #1 Info

    Is this a new purchase or a rental you currently own?

    When did you purchase this rental?

    What is the address of the rental property?

    What year was the home built?

    What is the finished square footage of this home? (do not include finished basement or attic)

    How many stories is the home? (do not include basement)

    How many full bathrooms are there?

    How many half bathrooms are there?

    How would you classify the quality level of the kitchen?
    builder’s grade | semi-custom | custom

    How would you classify the quality level of the bathroom(s)?
    builder’s grade | semi-custom | custom

    Is there a garage?

    What size is the attached garage?
    What size is the detached garage?

    Are there any other detached structures on the premises?

    Please provide more detail

    What is the exterior finish of the home? (check all that apply)

    What type of foundation does the home have? (check all that apply)

    Is basement finished?

    Is there a sump pump?

    Are there any auxiliary heat sources in the home? (check all that apply)

    How old (years) is the roof on the home?

    What is the roofing material?

    What type of central heating system is in the home?

    What is the age (years) of the heating system?

    What type of electrical service does this home have?

    Is this rental currently tenant-occupied, or will be in the next 30 days?

    Is the rental undergoing any renovations?

    Are lease agreements annual or short-term basis?

    Liability Information

    Is there, or will there be, a trampoline?

    Is the trampoline netted?

    Is the trampoline within a fenced yard?

    Is there a swimming pool?

    The pool is:

    Check all that apply:

    Pets, animals or livestock. Check any box that applies to your tenant(s).

    What breed(s) of dog(s) do your tenant have?

    How many dogs does your tenant have?
    What kind(s) of farm animals does your tenant have?

    How many farm animals do your tenant have?
    Please provide more detail about exotic animal(s)

    Does your tenant have any type of business operation in the home (ex. that generates higher than normal foot traffic)

    Please provide more detail

    Property Losses/Claims History Information

    In the past 5 years, have you filed any claims on any homeowner’s, landlord or renter’s policies?

    Please provide more detail

    Coverage Information

    IMPORTANT: Your rental policy does not cover your tenant’s personal belongings.
    It is strongly recommended they purchase a renter’s policy covering their personal property along with adequate personal liability coverage in the event they are liable for damage to your rental property.

    The standard minimum homeowner’s deductible we usually quote is $1,000.

    Please quote me with a
    deductible.

    Please let us know if you’d be interested in, or would like more info about the following coverages

    What date would you like this policy to begin

    Rental #2 Info

    Is this a new purchase or a rental you currently own?

    When did you purchase this rental?

    What is the address of the rental property?

    What year was the home built?

    What is the finished square footage of this home? (do not include finished basement or attic)

    How many stories is the home? (do not include basement)

    How many full bathrooms are there?

    How many half bathrooms are there?

    How would you classify the quality level of the kitchen?
    builder’s grade | semi-custom | custom

    How would you classify the quality level of the bathroom(s)?
    builder’s grade | semi-custom | custom

    Is there a garage?

    What size is the attached garage?
    What size is the detached garage?

    Are there any other detached structures on the premises?

    Please provide more detail

    What is the exterior finish of the home? (check all that apply)

    What type of foundation does the home have? (check all that apply)

    Is basement finished?

    Is there a sump pump?

    Are there any auxiliary heat sources in the home? (check all that apply)

    How old (years) is the roof on the home?

    What is the roofing material?

    What type of central heating system is in the home?

    What is the age (years) of the heating system?

    What type of electrical service does this home have?

    Is this rental currently tenant-occupied, or will be in the next 30 days?

    Is the rental undergoing any renovations?

    Are lease agreements annual or short-term basis?

    Liability Information

    Is there, or will there be, a trampoline?

    Is the trampoline netted?

    Is the trampoline within a fenced yard?

    Is there a swimming pool?

    The pool is:

    Check all that apply:

    Pets, animals or livestock. Check any box that applies to your tenant(s).

    What breed(s) of dog(s) do your tenant have?

    How many dogs does your tenant have?
    What kind(s) of farm animals does your tenant have?

    How many farm animals do your tenant have?
    Please provide more detail about exotic animal(s)

    Does your tenant have any type of business operation in the home (ex. that generates higher than normal foot traffic)

    Please provide more detail

    Property Losses/Claims History Information

    In the past 5 years, have you filed any claims on any homeowner’s, landlord or renter’s policies?

    Please provide more detail

    Coverage Information

    IMPORTANT: Your rental policy does not cover your tenant’s personal belongings.
    It is strongly recommended they purchase a renter’s policy covering their personal property along with adequate personal liability coverage in the event they are liable for damage to your rental property.

    The standard minimum homeowner’s deductible we usually quote is $1,000.

    Please quote me with a
    deductible.

    Please let us know if you’d be interested in, or would like more info about the following coverages

    What date would you like this policy to begin

    —–Renter’s Section—–

    Property Information

    What is the address of the new property you’re renting?

    Coverage Information

    How much personal property coverage would you like? (minimum is $20,000)

    Please choose a deductible

    Please let us know if you’d be interested in, or would like more info about the following coverages

    Liability Information

    How many household residents? (any who would consider this their primary residence.)

    If you’d like to provide additional information (optional):

    Is there, or will there be, a trampoline?

    Is the trampoline netted?

    Is the trampoline within a fenced yard?

    Is there a swimming pool?

    The pool is:

    Check all that apply:

    Pets, animals or livestock. Check any box that applies to you.

    What breed(s) of dog(s) do you have?

    How many dogs do you have?
    What kind(s) of farm animals do you have?

    How many farm animals do you have?
    Please provide more detail about exotic animal(s)

    Is there any type of business operation in the home/apartment? (ex. that generates higher than normal foot traffic)

    Please provide more detail

    Please choose an amount for personal liability coverage

    Property Losses/Claims History Information

    In the past 5 years, have you filed any claims on any homeowner’s or renter’s policies?

    Please provide more detail

    What date would you like this policy to begin

    Driver Information

    You’ve already entered driver information for yourself (and possibly co-applicant).

    How many other licensed drivers either live in household or regularly drive your vehicle(s)? (max. 6 for this form)

    Other Driver #1 Info

    List name for Other Driver #1

    Date of birth for Other Driver #1

    What is Other Driver #1‘s relation to you?

    Please enter driver’s license number for Other Driver #1. (not required for quote but helps for accuracy)

    Has Other Driver #1 had any accidents or tickets the past 5 years?

    Please explain
    Other Driver #2 Info

    List name for Other Driver #2

    Date of birth for Other Driver #2

    What is Other Driver #2‘s relation to you?

    Please enter driver’s license number for Other Driver #2. (not required for quote but helps for accuracy)

    Has Other Driver #2 had any accidents or tickets the past 5 years?

    Please explain
    Other Driver #3 Info

    List name for Other Driver #3

    Date of birth for Other Driver #3

    What is Other Driver #3‘s relation to you?

    Please enter driver’s license number for Other Driver #3. (not required for quote but helps for accuracy)

    Has Other Driver #3 had any accidents or tickets the past 5 years?

    Please explain
    Other Driver #4 Info

    List name for Other Driver #4

    Date of birth for Other Driver #4

    What is Other Driver #4‘s relation to you?

    Please enter driver’s license number for Other Driver #4. (not required for quote but helps for accuracy)

    Has Other Driver #4 had any accidents or tickets the past 5 years?

    Please explain
    Other Driver #5 Info

    List name for Other Driver #5

    Date of birth for Other Driver #5

    What is Other Driver #5‘s relation to you?

    Please enter driver’s license number for Other Driver #5. (not required for quote but helps for accuracy)

    Has Other Driver #5 had any accidents or tickets the past 5 years?

    Please explain
    Other Driver #6 Info

    List name for Other Driver #6

    Date of birth for Other Driver #6

    What is Other Driver #6‘s relation to you?

    Please enter driver’s license number for Other Driver #6. (not required for quote but helps for accuracy)

    Has Other Driver #6 had any accidents or tickets the past 5 years?

    Please explain

    Liability Limits

    Liability limits are available in two formats, Split & Combined limits.

    –Split Limits provide separate limits for bodily injury & property damage
    (ex. bodily injury $100,000 ea person/ $300,000 per acc./ property damage $100,000 per acc.)

    –Combined Single Limit (CSL) provides one single limit for bodily injury & property damage.
    (ex. $300,000 ea acc. CSL bodily injury & property damage combined)

    Select the liability limits for Bodily Injury to Others*

    Please enter desired limits:
    Select the liability limit for Property Damage of Others*

    Please enter the desired limits:

    * We will apply these same limits to the Un-Insured/Under-Insured Motorist Bodily Injury & Property Damage Coverage

    Select the limit for Medical Payments (per person/ for you and your passengers)

    —–Auto Section—–

    Current Coverage

    Do you currently have auto insurance?

    What company are you currently insured with?

    How long have you been insured with them?

    Have you had any coverage gaps or lapses in the last 5 years?

    How do you currently pay your auto insurance premium?

    Vehicle Information

    How many vehicles do you have registered to you and/or co-applicant? (max. 6 for this form)
    It is not recommended to insure your vehicles with multiple companies; please list all here.

    Vehicle 1 Info

    Enter VIN for Vehicle 1 (optional)

    Enter year, make & model

    Is this vehicle financed or leased?

    Did you buy this vehicle new or used?

    What year did you purchase it?

    Who is the vehicle registered to?

    Check any boxes that apply to this vehicle

    How is this vehicle primarily used?

    Please provide more detail

    Do you wish to carry physical damage coverage on this vehicle? (required if financed or leased)

    Select Comprehensive deductible


    Select Collision deductible


    Vehicle 2 Info

    Enter VIN for Vehicle 2 (optional)

    Enter year, make & model

    Is this vehicle financed or leased?

    Did you buy this vehicle new or used?

    What year did you purchase it?

    Who is the vehicle registered to?

    Check any boxes that apply to this vehicle

    How is this vehicle primarily used?

    Please provide more detail

    Do you wish to carry physical damage coverage on this vehicle? (required if financed or leased)

    Select Comprehensive deductible


    Select Collision deductible


    Vehicle 3 Info

    Enter VIN for Vehicle 3 (optional)

    Enter year, make & model

    Is this vehicle financed or leased?

    Did you buy this vehicle new or used?

    What year did you purchase it?

    Who is the vehicle registered to?

    Check any boxes that apply to this vehicle

    How is this vehicle primarily used?

    Please provide more detail

    Do you wish to carry physical damage coverage on this vehicle? (required if financed or leased)

    Select Comprehensive deductible


    Select Collision deductible


    Vehicle 4 Info

    Enter VIN for Vehicle 4 (optional)

    Enter year, make & model

    Is this vehicle financed or leased?

    Did you buy this vehicle new or used?

    What year did you purchase it?

    Who is the vehicle registered to?

    Check any boxes that apply to this vehicle

    How is this vehicle primarily used?

    Please provide more detail

    Do you wish to carry physical damage coverage on this vehicle? (required if financed or leased)

    Select Comprehensive deductible


    Select Collision deductible


    Vehicle 5 Info

    Enter VIN for Vehicle 5 (optional)

    Enter year, make & model

    Is this vehicle financed or leased?

    Did you buy this vehicle new or used?

    What year did you purchase it?

    Who is the vehicle registered to?

    Check any boxes that apply to this vehicle

    How is this vehicle primarily used?

    Please provide more detail

    Do you wish to carry physical damage coverage on this vehicle? (required if financed or leased)

    Select Comprehensive deductible


    Select Collision deductible


    Vehicle 6 Info

    Enter VIN for Vehicle 6 (optional)

    Enter year, make & model

    Is this vehicle financed or leased?

    Did you buy this vehicle new or used?

    What year did you purchase it?

    Who is the vehicle registered to?

    Check any boxes that apply to this vehicle

    How is this vehicle primarily used?

    Please provide more detail

    Do you wish to carry physical damage coverage on this vehicle? (required if financed or leased)

    Select Comprehensive deductible


    Select Collision deductible


    —–Motorcycle Section—–

    How many motorcycles are registered to you and/or co-applicant? (max. 4 for this form)

    Motorcycle 1 Info

    Enter VIN for Motorcycle 1 (optional)

    Enter year, make & model

    Is this vehicle a trike?

    What size is the engine (cc’s)?

    Is there a modified frame, turbo/nitrous kit, snorkel or lift kit?

    Does this motorcycle have anti-lock brakes?

    What is the current estimated value?

    Is this motorcycle financed?

    Did you buy this motorycle new or used?

    When did you purchase it?

    Who is the motorcycle registered to?

    Do you wish to carry physical damage coverage on this motorcycle? (required if financed)

    Select Comprehensive deductible

    Select Collision deductible

    Motorcycle 2 Info

    Enter VIN for Motorcycle 2 (optional)

    Enter year, make & model

    Is this vehicle a trike?

    What size is the engine (cc’s)?

    Is there a modified frame, turbo/nitrous kit, snorkel or lift kit?