Information Needed To Quote Your Insurance

Information Needed to Quote Your Insurance
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
How long have you been at your current address?*

3 or more yrsLess than 3 yrsAbout to move to the address above
What is the closing date or move date?

MonthDayYear
Date
Prior address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
My current 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

Primary Contacts for the household:*

	Name	Date of Birth	Marital Status	Occupation	Education	AAA Member?
#1
#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 rushed request?

Auto Insurance

Drivers:*

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

Do any drivers have any tickets, accidents, or claims filed in the last 5 yrs?*

YesNo

Are you willing to do a telematics (tracking) program to earn discounts for safe driving habits?*

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

Vehicles*

	Vehicle Yr and Model	Primary Driver	1 way mileage to work or school	Annual Miles	Use for Uber or Lyft?	Vehicle is parked:
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
Vehicle 6

Vehicles continued*

	Month and Year Purchased	Blind Spot Sensor?	Automatic Braking?	VIN (Vehicle Identification Number)	Vehicle Owner
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
Vehicle 6

Vehicle Coverages*

	Collision Deductible	Comprehensive Deductible	Towing	Vehicle Rental	Full Glass Coverage
1
2
3
4
5
6

Are you willing to look at a higher deductible to get a lower rate?*

YesNoDepends on how much I save
Are there any other coverages you want that aren't listed above?*

YesNo
What additional coverages do you want?
Do any of these vehicles have a hitch?*

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

OEM PartsAccident or Ticket forgivenessDisappearing deductibleGuaranteed Replacement for brand new vehiclesNone of the aboveOther
Want any of these optional coverages:*
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
Do you currently have auto insurance or are you listed as a driver on an insurance policy?*

YesNoNo, but I've had auto insurance within the last 30 days
What Insurance Company are you currently insured with? If you're not currently insured, answer "none". *
When does your policy renew again? (this would be on your insurance card)
How long have you been with this insurance company?*
How much do you currently pay for your insurance? We have no control over rates, but this can help us determine if something is missing. (Please include if this rate is per month, 6 months, etc.)*
If you've been with your current insurance company for less than 5yrs, how long have you been insured without a gap between policies?

	Bodily Injury	Property Damage	Uninsured/Underinsured Motorists	Medical Payments (put 0 if not carried)
Limits:

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 go through each one.*
Do you run a business out of your home? If so, please describe it.*
Are you currently insured for this home?*

YesNoNo, because I'm buying a new home
Address of new home (if different than above):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Current Home Deductible*
Are you willing to look at a higher deductible for a lower rate?*

YesNoDepends on how much I'll save
Current Insurance Company:*
How long have you been with your current company?*
Current Premium: We have no control over rates, but this helps us determine if we missed any optional coverages (Please include if this rate is per month, per year, etc.)*
Who pays the home premium?*

I doComes from my mortgage escrowOther
I prefer to pay:*
What is your renewal date (or closing date if buying a new home)?
As far as you know, have there been any claims in the last 5 yrs on the home or on your home/renters policies?*

YesNo

Please provide more information for all claims in the last 5 yrs.*

	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

Do you have any scheduled items on your current policy?*

YesNoUnsure
What do you have scheduled and what is the value(s)?*
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 CoverageNone of the above
Do you want any of the following optional coverages your current company may not offer?*

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
Do you personally have any:*
How much coverage do you currently carry? If you don't currently have renters, how much would it cost to replace all your personal property?*

Life Insurance

Who all are you wanting to cover?*

	Name	Date of Birth	Female or Male	Any Tobacco Use?
Person 1
Person 2
Person 3
Person 4

How much coverage are you looking for?*
What is your budget for life insurance? If unsure, please enter "not sure".*

Health Insurance

Who are you wanting coverage for?*

	Name	Date of Birth	Male or Female	Any Tobacco Use?
Person 1
Person 2
Person 3
Person 4
Person 5

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? *

Information Needed to Quote Your Insurance