Re-Quote My Policies
Name of Person Submitting this Form
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First Name
Last Name
Name of Primary Insured (if different than above)
First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Many companies have a paperless discount now. Should we run your quotes with the paperless discount? You would need an email address and if you'll want any documents printed (like insurance cards), you'll need access to a printer.
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Yes
No
Number of people in your household (everyone, not just drivers)
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My current living situation:
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I live in a home I own
I rent where I live
I live with friends/family
Other
People in your household and their occupations (please also include yourself) :
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Rows
Name
Occupation (student is an acceptable response)
Date of Birth (if we don't already have it)
Education
Gender on Driver's License or State ID
Marital Status
Person 1
Some High School
High School
Some College
Trade School
Associates
Bachelors
Masters
Doctorate/PHD
Female
Male
Single
Married
Widowed
Divorced
Separated
Person 2
Some High School
High School
Some College
Trade School
Associates
Bachelors
Masters
Doctorate/PHD
Female
Male
Single
Married
Widowed
Divorced
Separated
Person 3
Some High School
High School
Some College
Trade School
Associates
Bachelors
Masters
Doctorate/PHD
Female
Male
Single
Married
Widowed
Divorced
Separated
Person 4
Some High School
High School
Some College
Trade School
Associates
Bachelors
Masters
Doctorate/PHD
Female
Male
Single
Married
Widowed
Divorced
Separated
Person 5
Some High School
High School
Some College
Trade School
Associates
Bachelors
Masters
Doctorate/PHD
Female
Male
Single
Married
Widowed
Divorced
Separated
Person 6
Some High School
High School
Some College
Trade School
Associates
Bachelors
Masters
Doctorate/PHD
Female
Male
Single
Married
Widowed
Divorced
Separated
Who currently has the best credit in the household?
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Do you plan on any of the following changing in the next year?
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New driver or other driver change
New vehicle or selling a vehicle
Address change
Marital Status (will you be getting married in the next year)
Add a pool or trampoline
None of the above
What is the name and date of birth of the driver, and when do you plan on them getting their license?
When do you plan on getting this vehicle, and what type are you considering (electric vehicle, SUV, truck, car, classic vehicle, etc.)?
Where are you wanting to move to and when? Will you be buying a home when you move?
When do you plan on this change happening? Are you adding an in-ground pool, above-ground pool, or a trampoline?
What policies are we re-quoting for you?
Auto
Home
Renters
Other
Auto
How many vehicles do you own?
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Do you need to add any new vehicles?
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No
Yes
What is the year, make, model, and VIN for the new vehicle?
Any new drivers you haven't added to your policy yet?
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No
Yes
Please provide their name, date of birth, drivers license #, and occupation. Also, if they are a full time student, do they qualify for a good student discount (carrying a B average or better)?
Do any drivers have any new tickets, recent accidents, or recent claims?
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No
Yes
Please provide a date and description of the incident:
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Are any drivers full time students under the age of 25?
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Yes
No
List the names and most recent report card GPA for any students carrying at least a B average:
Vehicles:
*
Rows
Year and Make
Miles Driven Per Year
Blind Spot Detection?
Automatic Braking?
Month and
Year of Purchase?
Primary Driver
Vehicle Owner
Vehicle Use
1
Yes
No
Yes
No
To/from work/school
Pleasure Use
Business Use
Work from home
Farm Only Use
2
Yes
No
Yes
No
To/from work/school
Pleasure Use
Business Use
Work from home
Farm Only Use
3
Yes
No
Yes
No
To/from work/school
Pleasure Use
Business Use
Work from home
Farm Only Use
4
Yes
No
Yes
No
To/from work/school
Pleasure Use
Business Use
Work from home
Farm Only Use
5
Yes
No
Yes
No
To/from work/school
Pleasure Use
Business Use
Work from home
Farm Only Use
6
Yes
No
Yes
No
To/from work/school
Pleasure Use
Business Use
Work from home
Farm Only Use
Are any vehicles used for Uber, Lyft, Uber Eats, Door Dash, or any other similar service?
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No
Yes
Which vehicle(s) are used for these services?
Are these all the vehicles you own?
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Yes
No
Please provide a description of what we're not insuring? Some companies will not insure you if they don't have all your vehicles outside of collector vehicles, so this information is very important for us to find a good fit for you.
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A lot of companies are offering tracking programs to provide discounts for those that prove they are safe drivers when they're on the road. The startup discount will vary per company but usually ranges from 5%-15%. That upfront discount would be replaced with a discount up to 30% off your rates or could raise rates up to 30% with most companies. Would you be willing to do a program like this to earn extra discounts for safe driving habits?
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Yes, everyone in my household would be willing to do this
Yes, but only certain drivers would be willing to do this
No
Depends on the discount (if this is selected, we will include the discount and you'll have to ask for it to be removed).
Which drivers are willing to do the tracking?
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Do any of your vehicles have a hitch?
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No
Yes
What, if anything, do you haul with that vehicle?
What payment methods are you willing to do to save money?
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Automatic payments from a checking account
Automatic payments from a debit or credit card
Paid in full
None of the above
Do you want to look at a higher deductible to lower your rates?
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Yes
No
Any comments, questions, or anything we didn't cover on the auto section?
Homeowners
Do you have a deck?
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No
Yes
Square Footage of the Deck:
Do you have a porch?
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No
Yes
Square footage of the Porch:
Do you have any of the following:
Is your yard fenced?
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No
Yes
Do you have any dogs?
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Yes
No
Dogs
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Rows
Name
Age
Spayed/
Neutered
Breed (if mixed, please list known breeds, as we can't use "mixed")
Any Bite History?
Dog 1
Yes
No
No
Yes
Dog 2
Yes
No
No
Yes
Dog 3
Yes
No
No
Yes
Dog 4
Yes
No
No
Yes
Home Features (a number is required in each of these boxes)
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Rows
# of Full Baths
# of Half Baths
# of Solar Panels
Feature
Do you have a basement?
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Yes
No
What % of the basement would you say is finished?
*
Do you have a sump pump?
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Yes
No
Do you have a backup system to your sump pump?
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No
Yes, water powered
Yes, battery powered
Yes, generator powered
Do you have any smart home devices? (Nest Thermostat, smart water leak sensors, etc.)
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No
Yes
What smart home devices do you have?
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Do you have a wood burning stove?
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No
Yes
Was your wood burning stove professionally installed?
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No
Yes
Unsure
Do you have an alarm?
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No
Yes
Is your alarm:
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Local Only
Smart device that only alerts you
Central Reporting
Other
Are there any non-standard features we didn't cover? (Jacuzzi tubs, skylights, 3 or 4 season rooms, central vac, etc.) If nothing, please answer "none"
*
Do you have any detached structures on your property?
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No
Yes
Please provide more information on your detached structures
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Rows
What is the structure (garage, shed, etc)?
Yr Built or Installed
Approx Size
Type of heating device (None, gas or electric heater, fireplace, wood burning stove, etc.)?
Approximate Cost to Rebuilt Brand New
#1
#2
#3
#4
Updates (a number is required in each of these boxes, use year built if original to the home)
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Rows
Roof
Plumbing
Electrical
Heating
Cooling
Water Heater
Year last updated
Do you want any of the following coverages?
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Would you like to look at a different deductible option?
*
No
Yes, a higher deductible for a lower rate
Yes, a lower deductible for a higher rate
Are there any current issues with any building on your property, or issues on the property? This is extremely important, so please go through each one.
*
Do you run a business out of your home?
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No
Yes
Please describe the business. Also, please let us know how much (if any) and type of inventory you carry at a given time.
*
Any questions, comments, or anything we didn't cover on the home?
Renters
How much personal property coverage do you need? (how much would it cost to replace everything you moved into the place you live?)
*
Deductible you would would like us to quote?
*
Do you need any items scheduled (items worth more than $1500 for 1 item in categories like jewelry, arts, furs, guns, coins)
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No
Yes
Please describe the item(s) and provide current value(s):
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Do you want water backup coverage?
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No
Yes
How much coverage do you want?
*
# of units in your building
*
# of units between firewalls in the building (if known)
Is there a sprinkler system in the building?
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No
Yes, hallways only
Yes, in the units only
Yes, in the hallways and in the units
Do you have any dogs?
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No
Yes
Dogs:
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Rows
Name
Age
Spayed/Neutered
Breed
Any bite history?
Dog 1
Yes
No
Yes
No
Dog 2
Yes
No
Yes
No
Dog 3
Yes
No
Yes
No
Dog 4
Yes
No
Yes
No
Any additional comments for the renters?
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Anything else that will help us with re-quoting your policies?
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*
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