Selene M. Rico Agency Auto & Home Quote Form

Farmers Insurance

Client Information
Primary Named Insured

First NameMiddle Name
Last Name
Primary Insured Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDOB
Email
example@example.com
Cell Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Primary Insured Occupation
Affinity Discount (i.e.: Educator, Nurse, Police, etc. )
Spouse Name

First NameMiddle Name
Last Name
Spouse Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDOB
Spouse Occupation
Affinity Discount (i.e.: Educator, Nurse, Police, etc. )
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How Did You Hear About Our Agency?
Requested Insurance Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current Carrier Annual Premium
Vehicle 1
Year, Make, Model
Vin #
Odometer Reading
Vehicle 2
Year, Make, Model
Vin #
Odometer Reading
Vehicle 3
Year, Make, Model
Vin #
Odometer Reading
Current Policy Limits
If selected other, provide policy limits below
Current Policy Coverages

Other
How many other drivers in the household
Please include any children in the household
Other Driver Name

First NameMiddle Name
Last Name
Other Driver DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of Birth
Other Driver Name

First NameMiddle Name
Last Name
Other Driver DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of Birth
Other Driver Name

First NameMiddle Name
Last Name
Other Driver DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of Birth
Home Insurance
Current Carrier
Current Annual Premium
Year Built
Square Ft
Stories
Bedrooms
Roof Material
Interior Floor Covering

Other
Below please indicate what percentage of your interior floor covering is covered by each type of flooring you have selected above.
The interior floor coveringblanks(type checked above), coversblank (percent %) of my home.
The interior floor coveringblanks (other type checked above) coversblank (percent %) of home.
Countertop Type
Interior Wall Finish Type
(Paint/ Wall paper)
Exterior Materials

Other
Home Updates

Other
If Any Updates Checked, Please enter the year of the Updates
Does your home have a fire place?
If yes, what type?
Does your home have a chimney?
Home Features
Home Amenities
Garage/ Carport
If is so, is it attached?
Dogs? If so please include breed type.
Yes or no
Smoking or Non-smoking household
Insurance Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate insurance needs to active
Current Carrier Declaration Page

Cancelof
If you have any additional information you would like to include please provide it in the space below. Any questions you may have can be answered by calling our office phone number at 619-862-8602. Thank you so much for giving us an opportunity to help protect you and your family!
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Farmers Insurance

Home Insurance