Insurance Proposal Form
Please fill the form accurately for better assistance
What would make you leave your current Agency or Carrier?
Saving at least 15% or more
Better Coverage
Better Claims Service
Offer of a better client relationship
Phone Number
*
Ok with receiving text messages and email from BluePrint Risk
*
YES
E-mail
*
example@example.com
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Drivers License #
*
Education Level
Please Select
High School
Some College
Bachelors Degree
Masters
Doctorate
Married
Yes
No
Spouse/Other driver
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Drivers License #
Driver 3 / if there is one
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Drivers License #
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Own or Rent?
*
Own
Rent
Own Primary Residence and Other properties
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Auto Insurance Details
Are You Currently Insured
*
Yes
No
Number Of Drivers
*
Please Select
1
2
3
4
5
6
7
8
9
10 or more...
Number Of Vehicles
*
Please Select
1
2
3
4
5
6
7
8
9
10 or more...
Vehicle 1: Year/Make/Model
Vehicle 2: Year/Make/Model
Vehicle 3: Year/Make/Model
Vehicle 4: Year/Make/Model
Current Carrier Name
Expiration Date of Current Auto Insurance
-
Month
-
Day
Year
Date
Current Liability Limit
Please Select
25/50
50/100
100/300
250/500
500/500
Any tickets or accidents on any listed driver in the last 5 years. (please describe)
Any other drivers in the household or other details to assist us in creating a proper proposal?
Please upload your Auto Policies from your Current Carrier
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Or Take Photo of your Auto Policies from your Current Carrier
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Home Details
Year Built of Home
Sq Ft of Home
Age of Roof
Purchase Date of Current Home
-
Month
-
Day
Year
Date
Expiration Date of Current Home Insurance
-
Month
-
Day
Year
Date
Any home claims in the last 5 years
Yes
No
If you have claims please describe claims.
Gated Community
Yes
No
Is the house in a Homeowners Association
Yes
No
Do you have a dog?
Yes
No
Do you have a pool?
Yes
No
If yes what breed of Dog
Please upload your Home Policy from your current carrier.
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