Information not on your Declarations Pages

Information not on your Declarations Pages
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
How long have you been at your current address?
How long have you been at your current address?*

Buying a new homeLess than 3 yrs3 yrs or more
What date are you closing on the home?

MonthDayYear
Date
What was your prior address (or your current address if you're buying a new home or about to move)?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
My living situation is:

I own the home I live inI rent where I liveI live with friends/familyOther
Are you OK with paperless delivery of policy documents (most companies offer an extra discount for this)?*

YesNoDepends on the discount

Named Insureds (owners of the policy or policies) *

	Name	Date of Birth	Marital Status	Occupation	Education Level
Person 1
Person 2

Who has the best credit in the household? (Adults only, may get you a larger discount)*
How many people live in your home?
Everyone, not just drivers
Other than rate, is there another reason you're shopping your insurance?*
What policies are you wanting quotes for?*

AutoHomeUmbrellaRentersLifeHealthOther
How did you hear of us?
Which agent were you referred to or wanting to work with? If not referred to us and any agent in our office will work, please type "any".*
We tend to work on quotes in the order they come in. Do you have an urgent matter that would require us to work on this sooner?

YesNo
What date do you need this by?

MonthDayYear
Date
What is the reason for the urgent request?
Please provide your current policies here or email them to service@edenins.com.

Browse Files

Cancelof

Drivers:*

	Driver Name	Date of Birth	Driver's License Number	Education Level	Occupation (use "student" for full time students)	Gender as it is listed on your Driver's License	Marital Status
Driver 1
Driver 2
Driver 3
Driver 4
Driver 5
Driver 6

Does anyone have any tickets, accidents, or had to file a claim in the last 5 yrs?*

YesNo

Are you willing to do a telematics (tracking) program to try to get a better rate?*

Yes, all drivers are willing to do thisYes, only some drivers are willing to do thisDepends on the discountNo
Which drivers are willing to do the tracking?*
Which drivers (if any) qualify for the good student discount? (under 25, full time student, and at least a B average)

Vehicles*

Vehicles continued*

Do any of these vehicles have a hitch?*

NoYes
If yes, what do you pull or haul with that vehicle?
Want any of these optional coverages:*
Want any optional coverages:*

OEM PartsAccident or Ticket forgivenessDisappearing deductibleGuaranteed Replacement for brand new vehiclesNone of the aboveOther
How long have you been with your current insurance company for auto insurance?*
How long have you had continuous auto insurance without a gap between policies?*
How do you prefer to pay your auto insurance*

Pay in full (usually the largest discount)Monthly Automatic Payments from Checking or Savings (Usually the 2nd best rate)Monthly Recurring Credit CardMonthly Non-AutomaticOther

Homeowners Insurance
Do you have a basement?*

YesNo
What % of the basement is finished?*
How many full bathrooms do you have?*
How many half bathrooms do you have? *
Do you have a:*

Pool - Above GroundPool - In GroundTrampoline with nettingTrampoline without nettingDogNone of the above
Do you have a:*
If you have a dog(s), what is their name(s), breed(s) and age(s)?
Do you have a dog?*

YesNo

Dogs*

	Name	Age	Spayed/ Neutered	Breed (if mixed, please list known breeds, as we can't use "mixed")	Any Bite History?
Dog 1
Dog 2
Dog 3
Dog 4

Is your yard fenced in?*

YesNo
What (if any) smart home devices do you have? (Please put "none" if you don't have any)*
Do you have a sump pump?*

NoYes, with no backup systemYes, with a backup system
If you have any structures not attached to your home, are there any heating devices in those structures?*

NoYes

Year of Updates: (if unsure, put in your most reasonable guess, if still original to the house, put in the year the house was built)*

	Roof	Plumbing	Electrical	Heating	Cooling	Water Heater
Year of Update:

Are there any current issues with any building on your property, or issues on the property? This is extremely important, so please review the entire list.*
Do you run a business out of your home? If so, please describe it.*
Do you want any of the following optional coverages your current company may not offer?*

Guaranteed Replacement for the homeAll Risk Coverage for your Personal PropertyService Line CoverageEquipment Breakdown CoverageEarthquakeWater BackupNone of the above
Do you want any of the following optional coverages if you don't already carry them?*
How long have you been with your current company?*
If you've had any claims in the last 5 years, please provide date(s) and description(s). If no claims, enter "none"*
How is your home premium paid:*

From my escrow accountI pay in full for the yearI pay monthlyOther

Renters
Number of apartments in your building*
Is there a sprinkler system?*

NoYes, only in the hallwaysYes, only in the apartmentsYes, in the hallways and the apartments
Do you personally have any*

PoolsTrampolinesDogsNone of the above
If you don't currently have renters, how much would it cost to replace all your personal property?*

Who all are you wanting to cover?*

Who are you wanting coverage for?*

Do you have a specific plan, deductible, or co-pay in mind for your plan?*
To see if you qualify for a subsidy through the Affordable Care Act, what is the household annual income?

Umbrella
Umbrella policies provide more liability coverage should you run out of coverage on your underlying policies. For example, you have a car accident where you are at fault and you're covered. Their medical bills, physical rehab bills, prescriptions, missed time from work, etc all add up to $850,000. You auto policy pays up to the policy limit, let say $250,000. With an umbrella, that policy would cover the other $600,000. Without an umbrella, they would come after you for reimbursement. It can vary by State what they are able to come after, but usually they can garnish your wages, take any money you have in savings, take tax returns, and can force you to sell extras (extra car, boat, motorcycle, ATV, 2nd home, etc.). For this reason, we recommend you at least have more coverage than you have in total assets, while also factoring in your income level to protect that too.
How much coverage would you like a quote for? *

	Date	Who was this for?	Description of the incident	Cost if known (for claims/accidents)
Incident 1
Incident 2
Incident 3
Incident 4
Incident 5