Information Needed to Quote Your Insurance
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
How long have you been at your current address?
*
3 or more yrs
Less than 3 yrs
About to move to the address above
What is the closing date or move date?
-
Month
-
Day
Year
Date
Prior address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
My current living situation is:
*
I own the home I live in
I rent where I live
I live with friends/family
Other
Are you OK with paperless delivery of policy documents (most companies offer an extra discount for this)?
*
Yes
No
Depends on the discount
Primary Contacts for the household:
*
Name
Date of Birth
Marital Status
Occupation
Education
AAA Member?
#1
Married
Single
Separated
Divorced
High School
Some College
Trade School
Associates
Bachelors
Masters
Doctorate/PHD
No
Yes
#2
Married
Single
Separated
Divorced
High School
Some College
Trade School
Associates
Bachelors
Masters
Doctorate/PHD
No
Yes
Primary Contacts:
*
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?
*
Auto
Home
Umbrella
Renters
Life
Health
Other
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?
Yes
No
What date do you need this by?
-
Month
-
Day
Year
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
Some high school
High School Diploma
Some College
Trade School
Associates
Bachelors
Masters
Doctorate
Female
Male
Single
Married
Widowed
Divorced
Separated
Driver 2
Some high school
High School Diploma
Some College
Trade School
Associates
Bachelors
Masters
Doctorate
Female
Male
Single
Married
Widowed
Divorced
Separated
Driver 3
Some high school
High School Diploma
Some College
Trade School
Associates
Bachelors
Masters
Doctorate
Female
Male
Single
Married
Widowed
Divorced
Separated
Driver 4
Some high school
High School Diploma
Some College
Trade School
Associates
Bachelors
Masters
Doctorate
Female
Male
Single
Married
Widowed
Divorced
Separated
Driver 5
Some high school
High School Diploma
Some College
Trade School
Associates
Bachelors
Masters
Doctorate
Female
Male
Single
Married
Widowed
Divorced
Separated
Driver 6
Some high school
High School Diploma
Some College
Trade School
Associates
Bachelors
Masters
Doctorate
Female
Male
Single
Married
Widowed
Divorced
Separated
Do any drivers have any tickets, accidents, or claims filed in the last 5 yrs?
*
Yes
No
Please provide more information for all tickets/accidents/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
Are you willing to do a telematics (tracking) program to earn discounts for safe driving habits?
*
Yes, all drivers are willing to do this
Yes, but only some drivers are willing to do this
Depends on the discount
No
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
No
Yes
Garage
Off-street
On-street
Vehicle 2
No
Yes
Garage
Off-street
On-street
Vehicle 3
No
Yes
Garage
Off-street
On-street
Vehicle 4
No
Yes
Garage
Off-street
On-street
Vehicle 5
No
Yes
Garage
Off-street
On-street
Vehicle 6
No
Yes
Garage
Off-street
On-street
Vehicles continued
*
Month and Year Purchased
Blind Spot Sensor?
Automatic Braking?
VIN (Vehicle Identification Number)
Vehicle Owner
Vehicle 1
No
Yes
No
Yes
Vehicle 2
No
Yes
No
Yes
Vehicle 3
No
Yes
No
Yes
Vehicle 4
No
Yes
No
Yes
Vehicle 5
No
Yes
No
Yes
Vehicle 6
No
Yes
No
Yes
Vehicle Coverages
*
Collision Deductible
Comprehensive Deductible
Towing
Vehicle Rental
Full Glass Coverage
1
$0
$100
$250
$500
$1,000
No Coverage
$0
$100
$250
$500
$1,000
No Coverage
Yes
No
Yes
No
Yes
No
2
$0
$100
$250
$500
$1,000
No Coverage
$0
$100
$250
$500
$1,000
No Coverage
Yes
No
Yes
No
Yes
No
3
$0
$100
$250
$500
$1,000
No Coverage
$0
$100
$250
$500
$1,000
No Coverage
Yes
No
Yes
No
Yes
No
4
$0
$100
$250
$500
$1,000
No Coverage
$0
$100
$250
$500
$1,000
No Coverage
Yes
No
Yes
No
Yes
No
5
$0
$100
$250
$500
$1,000
No Coverage
$0
$100
$250
$500
$1,000
No Coverage
Yes
No
Yes
No
Yes
No
6
$0
$100
$250
$500
$1,000
No Coverage
$0
$100
$250
$500
$1,000
No Coverage
Yes
No
Yes
No
Yes
No
Do you have a travel trailer you want to insure?
*
Yes
No
Please provide the following for each travel trailer:
Year
Make
Model
Model Indicator or Number
VIN
# of slides
Trailer 1
Trailer 2
Trailer 3
Travel Trailer info continued
Length
# of slides
Current value
Price new
Purchase Year
Trailer 1
Trailer 2
Trailer 3
Travel Trailer use and coverage
Is it parked at a single location year round?
Is it ever rented to others?
Primary Use
Amount fo coverage for personal affects
Do you want roadside/towing coverage?
Trailer 1
Yes
No
Yes
No
Recreation
Primary residence
Taken to and from work locations
Used at a work location
Other
Yes
No
Trailer 2
Yes
No
Yes
No
Recreation
Primary residence
Taken to and from work locations
Used at a work location
Other
Yes
No
Trailer 3
Yes
No
Yes
No
Recreation
Primary residence
Taken to and from work locations
Used at a work location
Other
Yes
No
Trailer Coverages continued
Emergency Expense coverage?
Vacation Liability
Pest Damage Protection (must be 0-5 model years old)
Roof damage Protection (must be 0-5 model years old)
Trailer 1
No
$1k
$2k
$5k
I want more info
No
$10k
$25k
$50k
$100k
$250k
$300k
$500k
I want more info
Yes
No
I want more info
Yes
No
I want more info
Trailer 2
No
$1k
$2k
$5k
I want more info
No
$10k
$25k
$50k
$100k
$250k
$300k
$500k
I want more info
Yes
No
I want more info
Yes
No
I want more info
Trailer 3
No
$1k
$2k
$5k
I want more info
No
$10k
$25k
$50k
$100k
$250k
$300k
$500k
I want more info
Yes
No
I want more info
Yes
No
I want more info
Are you willing to look at a higher deductible to get a lower rate?
*
Yes
No
Depends on how much I save
Are there any other coverages you want that aren't listed above?
*
Yes
No
What additional coverages do you want?
Do any of these vehicles have a hitch?
*
No
Yes
If yes, what do you pull or haul with that vehicle?
Want any optional coverages:
OEM Parts
Accident or Ticket forgiveness
Disappearing deductible
Guaranteed Replacement for brand new vehicles
None of the above
Other
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 Card
Monthly Non-Automatic
Other
Do you currently have auto insurance or are you listed as a driver on an insurance policy?
*
Yes
No
No, 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)
Do you want us to use the renewal date for your quote?
*
Yes
No
What date should we use? For the best possible rates, we suggest at least 2 weeks from today.
*
-
Month
-
Day
Year
Date
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?
Current Liability Limits
*
Bodily Injury
Property Damage
Uninsured/Underinsured Motorists
Medical Payments (put 0 if not carried)
Limits:
$25,000/50,000
$50,000/100,000
$100,000/300,000
$250,000/500,000
$500,000/500,000
$500,000/1,000,000
$300,000 CSL
$500,000 CSL
$1,000,000 CSL
Unsure
$20,000
$25,000
$50,000
$100,000
$250,000
$500,000
$25,000/50,000
$50,000/100,000
$100,000/300,000
$250,000/500,000
$500,000/500,000
$500,000/1,000,000
$300,000 CSL
$500,000 CSL
$1,000,000 CSL
Unsure
Homeowners Insurance
Do you have a basement?
*
Yes
No
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 Ground
Pool - In Ground
Trampoline with netting
Trampoline without netting
Dog
None 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?
*
Yes
No
Dogs
*
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
Is your yard fenced in?
*
Yes
No
What (if any) smart home devices do you have? (Please put "none" if you don't have any)
*
Do you have a sump pump?
*
No
Yes, with no backup system
Yes, with a backup system
If you have any structures not attached to your home, are there any heating devices in those structures?
*
No
Yes
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.
*
Are you willing to fix all of the issues above immediately or ASAP?
*
Yes
No
Not Applicable
Which issues are you able to fix ASAP and which are you unable to?
*
Do you run a business out of your home? If so, please describe it.
*
Are you currently insured for this home?
*
Yes
No
No, because I'm buying a new home
Address of new home (if different than above):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Coverage Amounts: (would show on your current declaration)
*
Liability
Medical Payments
Dwelling Amount
Water/Sewer Backup
Earthquake
Mine Subsidence
Current
$100,000
$300,000
$500,000
$1,000,000
Unsure
No Coverage
$2,000
$5,000
$10,000
$15,000
$20,000
$25,000
$50,000
>$50,000
No
Yes
No
Yes
Current Home Deductible
*
Are you willing to look at a higher deductible for a lower rate?
*
Yes
No
Depends 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 do
Comes from my mortgage escrow
Other
I prefer to pay:
*
Annual
Monthly
Other
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?
*
Yes
No
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?
*
Yes
No
Unsure
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 home
All Risk Coverage for your Personal Property
Service Line Coverage
Equipment Breakdown Coverage
None 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?
*
No
Yes, only in the hallways
Yes, only in the apartments
Yes, in the hallways and the apartments
Do you personally have any
Pools
Trampolines
Dogs
None 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
Female
Male
No
Yes
Person 2
Female
Male
No
Yes
Person 3
Female
Male
No
Yes
Person 4
Female
Male
No
Yes
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
Male
Female
No
Yes
Person 2
Male
Female
No
Yes
Person 3
Male
Female
No
Yes
Person 4
Male
Female
No
Yes
Person 5
Male
Female
No
Yes
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?
*
$1 million
$2 million
$3 million
$4 million
More than $4 million
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