insurance quotes

     Are you over-paying for insurance? 

When was the last time you got shopped for insurance quotes? Do you know if you’re currently over-paying? We get it! It can be time-consuming and frustrating having to research multiple companies and calling each one for quotes.  

That’s where we come in!  

Wilkinson Insurance is an independent insurance agency representing multiple reputable A-rated companies who all bring a different a different focus and appetite to the market. As a result, this allows us to provide you with insurance quotes specific to your individual needs.  Furthermore, it allows us to save you time and most likely money.

Let us do the work for you! 

Take a few minutes and fill out the form below as it applies to you and we’ll begin working on quotes for you right away! If you’d rather send us a message requesting we contact you, leave us a message here.


Need help

    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.

    Your 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.)

    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. in-home daycare or one 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 for property losses is $1,000.

    Please quote me with a
    deductible.

    Please select the desired limit for personal liability coverage. (this protects you and household family members against bodily injury/property damage for which you're found legally liable)

    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. in-home daycare or one 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. in-home daycare or one 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. in-home daycare or one 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. in-home daycare or one 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?

    Would you (& other listed drivers) be interested in participating in any programs offered by companies to reward safe driving habits with discounts based on driving performance? (most are now smartphone app-based programs lasting about 90 days with possible final discounts up to 20-30%)

    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


    What date would you like this policy to begin?

    -----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?

    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 3 Info

    Enter VIN for Motorcycle 3 (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 4 Info

    Enter VIN for Motorcycle 4 (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

    -----Watercraft Section-----

    How many watercraft are registered to you and/or co-applicant? (max. 2 for this form)

    Watercraft 1 Info

    What is the hull ID number? (optional-- required only for policy issue)

    Enter year, make & model

    What is the hull length (feet)?

    What is the hull material?

    How many motors does this watercraft have?

    What is the motor's year and make?

    What is the total horsepower?

    What type of propulsion? more info

    Has the engine been modified to enhance performance?

    What is the watercraft's maximum speed?

    What is the current market value of the boat (including motor)?

    What year did you purchase this watercraft?

    Are you the original owner of this watercraft?

    Is the watercraft usually kept at your residence during boating season?

    Where, at your residence, is the watercraft kept?
    What offsite location is the watercraft kept during boating season?

    During the winter months, what is the zip code of the location where watercraft is stored?

    Select all that apply to use of the watercraft:

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

    Select Comprehensive deductible

    Select Collision deductible

    Do you have a trailer for the watercraft you'd like to insure against physical damage?

    What is the year and make of the trailer?

    What is the current market value of the trailer?

    Watercraft 2 Info

    What is the hull ID number? (optional-- required only for policy issue)

    Enter year, make & model

    What is the hull length (feet)?

    What is the hull material?

    How many motors does this watercraft have?

    What is the motor's year and make?

    What is the total horsepower?

    What type of propulsion? more info

    Has the engine been modified to enhance performance?

    What is the watercraft's maximum speed?

    What is the current market value of the boat (including motor)?

    What year did you purchase this watercraft?

    Are you the original owner of this watercraft?

    Is the watercraft usually kept at your residence during boating season?

    Where, at your residence, is the watercraft kept?
    What offsite location is the watercraft kept during boating season?

    During the winter months, what is the zip code of the location where watercraft is stored?

    Select all that apply to use of the watercraft:

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

    Select Comprehensive deductible

    Select Collision deductible

    Do you have a trailer for the watercraft you'd like to insure against physical damage?

    What is the year and make of the trailer?

    What is the current market value of the trailer?

    -----Travel Trailer Section-----

    Travel Trailer Year

    Travel Trailer Make

    Travel Trailer Model

    Travel Trailer VIN (17 characters)

    Length of travel trailer (ft.)

    Number of slide outs?

    How is travel trailer towed?
    bumper hitchbed hitch

    Date of purchase (best estimate if unknown)

    Are you the original owner?
    yesno

    Current value of travel trailer

    Garaging Zip Code

    Is travel trailer parked at a single location year round?
    yesno

    Is the trailer kept at a campground/RV park?

    Is the trailer permanently on blocks or permanent foundation?

    Have the trailer wheels been removed?

    Is there a permanently installed utility connection?

    Is the travel trailer a rented vehicle, ever rented to others, or used for business?
    yesno

    Is the travel trailer taken to/from work or used at a work location?
    yesno

    Primary vehicle use
    recreation useit's my primary residence

    What is the approximate number of days used per year?

    Is the travel trailer financed?
    yesno

    Name of financial institution

    Years of experience operating a travel trailer (in years. Enter 0 if none)

    Liability coverage is extended from the towing vehicle.

    Physical damage options:

    Select Comprehensive deductible

    Select Collision deductible

    Additional vacation liability (includes $10,000)
    yesno

    Personal Effects (round to nearest thousand dollars. Enter '0' if none)

    Roadside Coverage
    yesno

    -----Motorhome Section-----

    Enter VIN for motorhome (optional)

    Enter year, make & model

    Length of motorhome (ft.)

    Number of slide outs?

    Motorhome purchase year

    Are you the original owner?

    Current value of motorhome

    Garaging zip code

    Is motorhome a rented vehicle, ever rented to others or used for business?

    Is motorhome take to/from work or used at a work location?

    Is this motorhome your only household vehicle registered for street use?

    Primary motorhome use:

    Enter the number of days this motorhome is used per year (approx.)

    Is the motorhome financed?

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

    Select Comprehensive deductible (includes Mexico)


    Select Collision deductible (includes Mexico)

    Emergency expenses

    Vacation liability

    Personal effects (enter $ amount $0 to $99,000)

    -----Umbrella Section-----

    NOTE: We must insure your autos to be able to offer an umbrella

    Select the limit of liability for the umbrella:

    Would you like the umbrella to include excess Un-insured Motorist protection to you?

    Do you, or any household member, own an animal that is vicious or has previously bitten anyone?

    Have you had an umbrella policy canceled, declined or non-renewed in the past 5 years?

    Any liability claims or lawsuits (other than auto) against you or other household member in the past 5 years?

    Is there any business occurring on the premises, including farming, home-sharing, or daycare?

    Please explain:

    Is there an unfenced inground swimming pool?

    Are you, or any household member, a professional athlete, actor, celebrity or public figure of any kind?

    Do you, or any household member, hold a director or officer level position with a volunteer, civic or charitable organization?

    Please explain

    Any aircraft owned, leased, chartered or furnished for regular use?

    Number of owned powered watercraft (Enter 0 if none)

    Number of company-owned vehicles (Enter 0 if none)

    Number of rental properties owned (Enter 0 if none)

    Number of secondary/seasonal residences occupied by you (Enter 0 if none)

    Number of ATV/motorcycles owned (Enter 0 if none)

    Number of classic, antique or motorhomes owned (Enter 0 if none)

    -----Flood Section-----

    If you've requested a homeowner's quote, we have much of the information already to quote for flood

    Are you required by your lender to carry flood insurance?

    Do you wish to also cover personal property against flood damage?"

    How much personal property coverage would you like?

    Please select the desired deductible

    Is the address for this quote the same as your current address listed above?

    Please provide address of home for flood quote

    Please choose the construction type of this home

    Is this your primary residence?

    Any flood losses for this property in the last 5 years?

    How many losses in the past 5 years?

    What is the foundation type?

    What year was the home built?

    What is the square footage of the home?

    Are you required by your lender to carry flood insurance?

    Do you wish to also cover personal property against flood damage?"

    How much personal property coverage would you like?

    Please select the desired deductible

    -----Life Section-----

    What type of life insurance are you interested in?

    What is the primary reason you're looking for life insurance S(select all that apply)

    Please explain

    How much protection do you need? (consider total debt, 5-10 yrs of income, weddings/college for kids)

    How long would you like the coverage to last?

    What state were you born in?

    What is your height?

    What is your weight?

    Select all tobacco products you have ever used in the past (check all that apply)

    When did you last use?

    Do you still use?

    How often do you use?

    Have you lost a parent, sibling, or child to cancer or heart issues who was younger than 60 years old?

    Do you take medication for high blood pressure?

    Do you take medication for high cholesterol?

    List any medications you are currently taking (if any)

    Do you have any health problems or family medical history?

    Please explain
    Does your co-applicant also want a quote for life insurance?

    What type of life insurance is your co-applicant interested in?

    What is the primary reason your co-applicant is looking for life insurance S(select all that apply)

    Please explain

    How much protection does your co-applicant need? (consider total debt, 5-10 yrs of income, weddings/college for kids)

    How long would your co-applicant like the coverage to last?

    What state was your co-applicant born in?

    What is your co-applicant's height?

    What is your co-applicant's weight?

    Select all tobacco products your co-applicant has ever used in the past (check all that apply)

    When did your co-applicant last use?

    Does your co-applicant still use?

    How often does your co-applicant use?

    Has your co-applicant lost a parent, sibling, or child to cancer or heart issues who was younger than 60 years old?

    Does your co-applicant take medication for high blood pressure?

    Do your co-applicant take medication for high cholesterol?

    List any medications your co-applicant is currently taking (if any)

    Does your co-applicant have any health problems or family medical history?

    Please explain

    Please tell us how you heard about our agency?

    Who referred you? (We have a referral program and would like to thank the person who referred you!)
    Please explain

    Additional remarks (optional)