Re-Quote My Policies

Re-Quote My Policies
Name of Person Submitting this Form*

First NameLast Name
Name of Primary Insured (if different than above)

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
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.*

YesNo
Number of people in your household (everyone, not just drivers)*
My current living situation:*

I live in a home I ownI rent where I liveI live with friends/familyOther

People in your household and their occupations (please also include yourself) :*

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
Person 2
Person 3
Person 4
Person 5
Person 6

Who currently has the best credit in the household?*
Do you plan on any of the following changing in the next year?*

New driver or other driver changeNew vehicle or selling a vehicleAddress changeMarital Status (will you be getting married in the next year)Add a pool or trampolineNone 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?

AutoHomeRentersOther

How many vehicles do you own?*
Do you need to add any new vehicles?*

NoYes
What is the year, make, model, and VIN for the new vehicle?
Any new drivers you haven't added to your policy yet?*

NoYes
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?*

NoYes
Please provide a date and description of the incident:*
Are any drivers full time students under the age of 25?*

YesNo
List the names and most recent report card GPA for any students carrying at least a B average:

Vehicles:*

Are any vehicles used for Uber, Lyft, Uber Eats, Door Dash, or any other similar service?*

NoYes
Which vehicle(s) are used for these services?
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?*

Yes, everyone in my household would be willing to do thisYes, but only certain drivers would be willing to do thisNoDepends 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?*
Do any of your vehicles have a hitch?*

NoYes
What, if anything, do you haul with that vehicle?
What payment methods are you willing to do to save money?*

Automatic payments from a checking accountAutomatic payments from a debit or credit cardPaid in fullNone of the above
Do you want to look at a higher deductible to lower your rates?*

YesNo
Any comments, questions, or anything we didn't cover above?

Do you have a deck?*

NoYes
Square Footage of the Deck:
Do you have a porch?*

NoYes
Square footage of the Porch:
Do you have any of the following:*

Trampoline with nettingTrampoline without nettingAbove ground poolIn-ground poolDogNone of the above
Do you have any of the following:
Is your yard fenced?*

NoYes
Do you have any dogs?*

YesNo

Home Features (a number is required in each of these boxes)*

Rows	# of Full Baths	# of Half Baths	# of Solar Panels
Feature

Do you have a basement?*

YesNo
What % of the basement would you say is finished? *
Do you have a sump pump?*

YesNo
Do you have a backup system to your sump pump?*

NoYes, water poweredYes, battery poweredYes, generator powered
Do you have any smart home devices? (Nest Thermostat, smart water leak sensors, etc.)*

NoYes
What smart home devices do you have? *
Do you have a wood burning stove?*

NoYes
Was your wood burning stove professionally installed?*

NoYesUnsure
Do you have an alarm?*

NoYes
Is your alarm:*

Local OnlySmart device that only alerts youCentral ReportingOther
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?*

NoYes

What are they, and do they have any heating devices in them? (please provide approximate age, size, and if they have heating, what type of heating device)*

Updates (a number is required in each of these boxes, use year built if original to the home)*

Rows	Roof	Plumbing	Electrical	Heating	Cooling	Water Heater
Year last updated

Do you want any of the following coverages?*
Do you want any of the following coverages?*
Would you like to look at a different deductible option?*

NoYes, a higher deductible for a lower rateYes, 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.*
Please describe the issues with the home:
Do you run a business out of your home?*

NoYes
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?

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)*

NoYes
Please describe the item(s) and provide current value(s):*
Do you want water backup coverage?*

NoYes
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?*

NoYes, hallways onlyYes, in the units onlyYes, in the hallways and in the units
Do you have any dogs?*

NoYes

Rows	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

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