MIG13, LLC
Copyright MIG13, LLC © 2022. All rights reserved.
Today's Date
 /
Month
 /
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
About You [Named Insured's / Owner(s) / Occupant(s)]
*
Rows
Full Name
Date of Birth
Relationship
Occupation (used in rating by some carriers)
Highest Level of Education
(used in rating by some carriers)
Person #1
High School
Trade School
Some College
College (Bachelors)
College (Masters)
College (PhD)
Person #2
High School
Trade School
Some College
College (Bachelors)
College (Masters)
College (PhD)
Person #3
High School
Trade School
Some College
College (Bachelors)
College (Masters)
College (PhD)
Person #4
High School
Trade School
Some College
College (Bachelors)
College (Masters)
College (PhD)
Is there a LLC, Trust, or other entity we will need to list?
[if listed on the title or deed]
Phone Number
*
[Best number to reach you at]
Format: (000) 000-0000.
Alternate phone number
[Please enter an alternate phone number]
Format: (000) 000-0000.
Email
*
[example@example.com]
How did you hear about us?
*
Friend
B2B (Example: Realtor)
Web
Advertisement
Walk-in
Other
Your friend's name?
The name of the business that referred you and the person that works there?
What advertisement?
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Type of Insurance You Need Quoted Today?
Type of Insurance you need quoted today...choose one.
Auto Insurance (3)
Home Insurance (Primary or Secondary/Vacation Home)(4)
Home Insurance (Rented to Others)(5)
Condo Insurance (6)
Umbrella Liability Insurance (7)
Mobile Home Insurance (8)
Builders Risk Insurance (9)
Renters Insurance (10)
Commercial Auto (11)
Commercial Property (12)
Artisan Contractors / Commercial Liability / Business Owners Policy (13)
Boat Insurance (14)
Jet Ski Insurance (15)
Motorcycle (16)
Golf Cart (17)
Life Insurance (18)
Flood Insurance (19)
Other / Not Listed (20)
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Auto Insurance
Home garaging address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Driver Information
*
Rows
Full Driver Name (as listed on license)
DOB
# Years U.S. Licensed
Occupation
Primarily drives which vehicle?
Driver's License #
State Licensed
Driver #1
Driver #2
Driver #3
Driver #4
Driver #5
Driver #6
Auto Owned by Named Insured(s)
*
Rows
Year
Make (ex: BMW)
Model (ex: 330 Ci)
Vehicle Type (ex: Sedan, Coupe, Pickup, Van, SUV)
Vehicle Identification Number (VIN), (typically 17 characters long)
Owned, Bank Financed, or Leased? (ex: O, B, or L)
Primary Use: To Work (how far each way), Pleasure, Business (ex: W-7, P, B)
Garaging Zip
Vehicle #1
Vehicle #2
Vehicle #3
Vehicle #4
Vehicle #5
Vehicle #6
Prior Insurance Info
*
Rows
Name of Company? (if none, Type NONE)
How long have you had this policy? (years/months)
Policy Number?
Next Expiration Date?
Prior Liability Limit? (ex: 100/300/100)
CURRENT POLICY
Prior Policy (if less than one year)
Choose a preferred Liability Limit (per person/per accident/property damage) (to others)
*
Rows
250/500/100
100/300/100
50/100/50
25/50/25
10/20/10
Liability (Choose one)
Choose a preferred Uninsured Motorist Limit (per person/per accident) (for you)
*
Rows
$250k/$500k
$100k/$300k
$50k/$100k
$25k/$50k
$10k/$20k
Do Not Want Cov'g
UM Unstacked
UM Stacked
Personal Injury Limit/Deductible (typical FL policy covers 80% of medically necessary expenses, 60% of lost wages, and $5,000 death benefit)
*
Rows
No Deductible
$250 Ded
$500 Ded
$1,000 Ded
PIP $10,000
PIP w/o Lost Wages (if retired or unemployed)
Medical Payments coverage covers expenses related to vehicular accidents. Also called "MedPay", it covers you and any passengers in your vehicle, any pedestrians you may injure, and you - if you are riding as a passenger in another vehicle or are injured by a vehicle as a pedestrian, bike rider, or public transportation rider.
*
Rows
$2,000
$5,000
$10,000
Do Not Want Cov'g
Med Pay
Choose a Collision Deductible for each of YOUR vehicles
*
Rows
$1,000
$500
$250
Do Not Want Cov'g
Coll Ded Veh #1
Coll Ded Veh #2
Coll Ded Veh #3
Coll Ded Veh #4
Coll Ded Veh #5
Coll Ded Veh #6
Choose a Comprehensive Deductible for each of your vehicles (includes fire, theft, flood, vandalism, broken glass)
*
Rows
$1,000
$500
$250
$100
Do Not Want Cov'g
Comp Ded Veh #1
Comp Ded Veh #2
Comp Ded Veh #3
Comp Ded Veh #4
Comp Ded Veh #5
Comp Ded Veh #6
Rental Reimbursement Limit (if your car is out of service due to an accident)
*
Rows
$30/day (max $900)
$40/day (max $1,200)
$50/day (max $1,500)
Do Not Want Cov'g
Rental Veh #1
Rental Veh #2
Rental Veh #3
Rental Veh #4
Rental Veh #5
Rental Veh #6
Special requests for coverage, additional details, or questions
*
Ex: Mailing address, if different. Child away at school with vehicle. (If none, Type NONE)
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Home Insurance
Primary and Secondary (Vacation)
Physical Address of Dwelling
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary/Secondary?
*
Please Select
Primary
Secondary
(Note: Primary qualifies for homestead exemption)
How many months a year do you (will you) occupy the home?
*
Mailing address?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name(s) exactly as it appears on the deed (or will appear on the deed)
*
Or will appear after closing
County?
*
NOTE: We will pull the property records from the county's property appraisal site.
Closing Date / (or Expiration Date of Current Policy)
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Purchase Price
*
Market Value
*
Realtor Contact (name, telephone number, email)
*
if none, type NONE (* this info helps us coordinate with all parties)
Lender Contact (name, telephone number, email)
*
if none, type NONE (* this info helps us coordinate with all parties)
Last Year the Roof was Replaced or Installed?
*
Pool/Trampoline (check all that apply)
*
No pool
In Ground
Above Ground
Slide/Dive Board
Fenced
Detached (not part of the home's foundation slab)
No Trampoline
Animals? / Breed? / Bite History?
*
(If none, type NONE)
Please describe property insurance losses in the last 5 years
*
Date: Description (if none, type NONE)
Most of the time we can pull the details of your home from the county property appraisers website, however, if you are in the course of construction for a new home we will need the details about your home listed below.
Sq ft of the living space, Style of the home, # of stories, # of bedrooms, #baths, other rooms, garage or carport size, screened porch size, pool size, fencing, dock, and any other details and finish that apply.
If you are constructing a new home, please insert an image of the home as it is expected to look when complete.
Browse Files
Drag and drop files here
Choose a file
(Can be the model sales brochure)
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of
Security System? (choose all that apply)
*
Local fire alarms and deadbolts on all exterior doors
Central burglar and fire (will need certificate from provider)
Sprinklers (all rooms)
Gated Entrance (unmanned)
Gated Entrance (manned 24 hrs)
Other
The following can help lower your insurance rate for your home or investment property:
*
Rows
I HAVE THIS!
I have ordered this!
Don't have this and have not ordered
A signed Mitigation Report from a certified engineer within the last 3 years.
A 4-point inspection (usually completed for older homes that have been renovated).
A roof certification report (gives a remaining useful life for the roof)
Special requests for coverage, additional details, or questions
*
Ex: Jewelry, Guns, Artwork, Wine Collections (if none, type NONE)
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Home Insurance (Rented to Others)
Daily, Weekly, Monthly, Annually
Physical Address of Dwelling
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name(s) exactly as it appears on the deed
*
Or will appear after closing
Mailing Address of Owner
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County?
*
NOTE: We will pull the property records from the county's property appraisal site.
Closing Date / (or Expiration Date of Current Policy)
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
If applicable
Purchase Price
*
Market Value
*
Realtor Contact (name, telephone number, email)
*
if none, type NONE
Lender Contact (name, telephone number, email)
*
if none, type NONE
Last Year Roof Replaced?
*
Security System (choose all that apply)
*
Local fire alarms and deadbolts on all exterior doors
Central burglar and fire (will need certificate from provider)
Sprinklered (all rooms)
Gated entrance (unmanned)
Gated entrance (manned 24 hour)
Other
The following can help lower your insurance rate for your home or investment property:
*
Rows
I HAVE THIS!
I have ordered this!
Don't have this and haven't ordered
A signed Mitigation Report from a certified engineer within the last 3 years.
A 4-point inspection (usually completed for older homes that have been renovated).
A roof certification report (gives a remaining useful life for the roof)
Special requests for coverage, additional details, or questions
*
(if none, Type NONE)
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Condominium Owners Insurance
Association Name
*
Physical Address of Unit
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County?
*
NOTE: We will pull the property records from the county's property appraisal site.
Mailing Address (if different from Property Address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name(s) exactly as it appears on the title
*
Or will appear at closing
Closing Date (if applicable) or Current Ins Expiration Date
*
 /
Month
 /
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Unit Information
*
Rows
Occupancy?
If Tenant Occupied
# of floors in bldg
# of units in bldg
About Your Unit
Primary
Secondary
Seasonal
Rented to Others
Daily
Weekly
Monthly
Annually
Updates to the Unit/Building? Roof / Electric / Plumbing / Windows?
*
if none, type NONE
Building (Any special features or upgrades completed on your Unit?)
*
If none, type NONE
Security System (check all that apply)
*
Local fire alarms and deadbolts on all exterior doors
Central burglar and fire (will need certificate from provider)
Sprinklered (all rooms)
Gated entrance (unmanned)
Gated entrance (manned 24 hour)
Other
Contents (Estimated $$$ value of your contents)
*
Dog(s)? Type(s)
*
if none, type NONE
Mortgage Company / Leinholder
*
if none, type NONE
Loan #
*
if none, type NONE
Do you have an Umbrella Liability Policy?
*
Umbrella policies usually require underlying liability of $300,000 or greater
The following can help lower your insurance rate for your home or investment property:
*
Rows
I HAVE THIS!
I have ordered this!
Don't have this and have not ordered
A signed Mitigation Report from a certified engineer within the last 3 years.
A 4-point inspection (usually completed for older homes that have been renovated).
A roof certification report (gives a remaining useful life for the roof)
Special requests for coverage, additional details, or questions
*
Ex: Jewelry, Guns, Fine Arts, Wine Collections... (if none, Type NONE)
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Umbrella Liability Insurance
* Requires adjustments in underlying Auto & Home liability limits
Physical Address of Your Home
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different from Physical Address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Amount of Insurance Requested
*
$1,000,000
$2,000,000
$5,000,000
$10,000,000
Do you want Uninsured/Underinsured Motorist Excess Liability of $1,000,000?
*
* Requires the Auto Policy have a minimum required UM Limit depending on the insurer
Auto Liability Limit
*
* Umbrella usually requires a minimum auto liability limit of $250k/$500K
Home Liability Limit
*
* Umbrella usually requires a minimum home liability limit of $300k
Number of Rental Properties
*
What other motorized vehicles do you own?
*
Please list type and number
Do you own dogs? If so, what breeds?
*
Special requests for coverage, additional details, or questions
*
(if none, Type NONE)
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Mobile Home Insurance
Physical Address of Property
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County?
*
NOTE: We will pull the property records from the county's property appraisal site.
Mailing Address (if different from Physical Address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name(s) exactly as it appears on the deed
*
Or will appear after closing
Occupancy
*
Primary
Secondary/Vacation Home
Rented to Others
Mobile Home Details
*
Rows
Year
Length
Width
Make
Model
Purchase Date
Purchase Price
Skirted?
Tied Down
MH Details
YES
NO
YES
NO
Attached/Unattached Structures
*
Description and Value
The following can help lower your insurance rate for your home or investment property:
*
Rows
I HAVE THIS!
I have ordered this!
Don't have this and have not ordered
A signed Mitigation Report from a certified engineer within the last 3 years.
A 4-point inspection (usually completed for older homes that have been renovated).
A roof certification report (gives a remaining useful life for the roof)
Additional Information, request for coverages, or questions
*
(if none, Type NONE)
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Builders Risk
Homes or Business Properties in the course of construction
Your Construction Project is....
*
Please Select
New Construction
Remodeling
Installation
Risk Type
*
Residential
Commercial
Insured Information
*
Rows
Mailing Address
Business Type
Description
Insured Information
Corporation
Individual
Joint Venture
LLC
Partnership
Other
Owner/Contractor
Owner
Contractor
Builder/Contractor Information
*
Rows
Full Name
Years of Experience
# of Structures Built in the Last 12 months
Projected # of Structures to be built/remodeled in the next 12 months
Loss History (last 3 years)
Builder/Contractor Information
Project Information
*
Rows
Total Completed Value (excluding cost of land)
Description of Construction/Installation Project
Type of Construction Materials
Any Additional Interested Parties
Project Information
Property Information
*
Rows
Address, including County
Type of Property
Square Footage
Number of Stories
Effective Date Needed
Property Information
Residential
Commercial
Mailing Address (if different from Physical Address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Information, Requests for Coverages, or Questions
*
(if none, Type NONE)
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Renters Insurance
Address of Rental
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different from Physical Address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Insurance Information
*
Rows
I have none
Company Name (not Agency)
Policy Expiration Date
Premium Amount
Amount Insured For
List Claims (last 3 years)
Current Insurance Information
Dwelling Information
*
Rows
Living Square Feet
Number of Units in Your Building
What Floor are you on?
Year Built
Smoke Detectors?
Fire Extinguisher
Deadbolt Locks all exterior doors?
Central Station Fire
Central Station Burglar
Fire Sprinklers in Unit?
Dwelling Information
Desired Coverages
*
Rows
Deductible
Liability Limit
Value of Your Contents
Other Coverages Desired
Desired Coverages
$500
$1,000
$100,000
$300,000
Additional information, request for coverages, or questions
*
(if none, Type NONE)
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Commercial Auto
Small (1-5 units), Fleets (6+ units, please call our office at 305-451-4788)
Name of Business / In Business Since?
Please describe the business operations
Address of the Business
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Driver Information
*
Rows
Driver #1
Driver #2
Driver #3
Driver #4
Driver #5
Full Name
DOB
# Years U.S. Licensed
Occupation
Primarily drives vehicle #?
License #
State Licensed
Autos/Trucks owned by the Business
*
Rows
Year
Make (ex: Ford)
Model (ex: F150)
Vehicle Type (ex: Trailer, P/U, Van, SUV)
Vehicle Identification Number (VIN)
Owned, Bank Financed, or Leased?
Primary Use: Business or Personal, or Both
Gross Vehicle Weight
Radius of Operation
Jobsites per Day
Garaging Zip
Stated Value of Vehicle
Vehicle #1
Vehicle #2
Vehicle #3
Vehicle #4
Vehicle #5
Prior Coverage Information
*
Rows
Continuous Coverage
Prior Insurance Company (not Agency)
Prior BI Coverage
Prior Expiration Date
Prior Coverage Information
12 months or more continuous Commercial Vehicle Policy with no lapse in coverage
12 months or more continuous Personal Vehicle Policy with no lapse in coverage
No Prior Insurance Coverage
Additional information, request for coverages, or questions
*
if none, Type NONE
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Commercial Property
Legal Name of the Property
*
Property Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Address of the Owner
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please describe the occupancy(s) of the building
*
Prior Coverage Information
*
Rows
Continuous Coverage
Prior Insurance Company (not Agency)
Prior BI Coverage
Prior Expiration Date
Prior Coverage Information
12 months or more continuous Commercial Vehicle Policy with no lapse in coverage
12 months or more continuous Personal Vehicle Policy with no lapse in coverage
No Prior Insurance Coverage
Property Information
*
Rows
County
Total Square Feet
Construction Type
Year Built
# of Stories
Update Year Roof
Update Year Plumbing
Update Year Electrical
Update Year HVAC
Percent Occupied
Property Information
Building Coverage $$$
*
Estimated
Contents Coverage $$$
*
Estimated
Leinholder, or other Interested Party
*
Type NONE, if none
Additional information, request for coverages, or questions
*
If none, please Type NONE
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Artisan Contractors / Commercial Liability / Business Owners Policy (BOP)
Legal Name of Business
*
Include Entity Type: S Corp, C Corp, LLC, Individual
Full Names of All Owners
*
Address of Business
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please fully describe the business operations
*
Date Your Business Began
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Website
*
Number of Employees
*
Estimated Gross Sales Receipts $$$
*
Prior Coverage Information (if none, type NONE)
*
Rows
Prior Insurance Company (not Agency)
Prior Liability Coverage Limit
Prior Expiration Date
Prior Coverage Information
Location Information
*
Rows
County
Total Square Feet
Percent Occupied
Construction Type
Year Built
# of Stories
Update Year Roof
Update Year Plumbing
Update Year Electrical
Update Year HVAC
Property Information
Yes
No
Do you need Building Coverage (or Build Out Coverage, if leasing)? How much?
*
Estimated Value $$$
Do you need Contents Coverage? How much?
*
Estimated Value $$$
Do you need Tools Covered? How much?
*
Estimated Value $$$
Additional information, request for coverages, or questions
*
if none, please Type NONE
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Boat Insurance
Power and Sail
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mooring Zip / Mooring Type (Dock-Slip, Trailer, Lift, Rack, Other) / Facility Name
*
Ex: 33037/Dry Stack/Blue Water Marina (type SAME if it is the same as the address listed above)
Use?
*
Please Select
Private Pleasure
Captain Charter
Bare Boat Charter
Racing
Watercraft
*
Rows
Boat #1
Boat #2
Boat #3
Boat Type (Ex: Center Console)
Year
Length (ft)
Make (Ex:Contender)
Model (Ex: 25 Bay)
Hull ID #
Name of Boat/Yacht
State of Registration
Registration #
Vessel Flag
Date Purchased
Purchase Price
Type (Power, Multihull, Sail, or Houseboat)
Construction (Fiberglass, Wood, Aluminum, Kevlar/Carbon Fiber, Steel, Other)
Engine Manufacturer/Model
Year Built
Serial #
Fuel (Gas/Diesel/Electric)
Propulsion (Inboard, Outboard, I/O, Jetdrive, Pod Drive)
Engine(s): Single, Twin, Triples, Quad
Horsepower - Each
Max Speed
Fuel Tanks (Metal, Fiberglass, Plastic)
Auxiliary Generator: Diesel or Gas?
Current Survey? (drydock or afloat)
Date of Survey
# of Fire Extinguishers
Total Years Boating Experience
Navigation/Safety Equipment/Security
*
Auto Fire Extinguisher
Fume Detector
Radar
GPS
Depth Finder
Auto Pilot
VHF Radio
Theft Alarm
Tracking Device
Engine Alarm
Secured Building
Surveillance System
Locked Fence Enclosure
Yacht Controller
Other
Navigation Area
*
Coastal Florida
Bahamas
Caribbean
Other
Boating Courses
*
None
US Power Squadron
US Coast Guard Auxiliary
Captain's License
Other
Boats Previously Owned
Rows
Make/Model
Size
Waters Navigated
Dates
Previous #1
Previous #2
Previous #3
Loss History (Details, Date, Carrier, Amount)
*
(If NONE, state NONE)
Because Florida boatowners insurance requires detailed information to get a quote from our partner carriers, our marine expert will be in touch with you as soon as possible if anything else is needed. (Please list any trailer information below -- Year, Make, Model, Serial #, Value).
*
(if NONE, type NONE)
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Jet Ski Insurance
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mooring Zip / Facility Name
*
Prior Coverage Information
*
Rows
Prior Insurance Company (not Agency)
Prior BI Coverage
Prior Expiration Date
No Prior Boat Insurance
Prior Coverage Information
Drivers
*
Rows
Driver 1
Driver 2
Driver 3
Driver 4
Name
Date of Birth
Drivers License # / State
Jetski
*
Rows
Jetski #1
Jetski #2
Jetski #3
Year
Length
Make
Model
Hull ID
Horsepower
Max Speed
Include Trailer for Rating?
Boater Safety Course (please list)
Comprehensive and Collision Deductible
Liability Limit Desired
Stated Value
Additional information, request for coverages, or questions
*
if none, please Type NONE
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Motorcycle Insurance
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Prior Coverage Information
*
Rows
Prior Insurance Company (not Agency)
Prior BI Coverage
Prior Expiration Date
No Prior Motorcycle Insurance
Prior Coverage Information
Drivers
*
Rows
Driver 1
Driver 2
Driver 3
Driver 4
Name
Date of Birth
Drivers License # / State
Motorcycle Info
*
Rows
Motorcycle #1
Motorcycle #2
Motorcycle #3
Year
Make
Model
CC's / Horsepower
Include Trailer for Rating?
Cycling Course? (please list)
Comprehensive and Collision Deductible
Liability Limit Desired
Additional information, request for coverages, or questions
*
if none, please Type NONE
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Golf Cart Insurance
Off Road and Street Legal
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Drivers
*
Rows
Driver 1
Driver 2
Driver 3
Driver 4
Name
Date of Birth
Drivers License # / State
Prior Coverage Information
*
Rows
Prior Insurance Company (not Agency)
Prior BI Coverage
Prior Expiration Date
No Prior Golf Cart Insurance
Prior Coverage Information
Golf Cart Info
*
Rows
Golfcart #1
Golfcart #2
Year
Make
Model
CC's / Horsepower
Include Trailer for Rating?
Drivers Course? (please list)
Comprehensive and Collision Deductible
Liability Limit Desired
Additional information, request for coverages, or questions
*
if none, please Type NONE
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Life Insurance
Term, Universal, Whole Life, and Annuities. We work with our large brokerage partner to find you the right coverage at the best price.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Life Insurance Info
*
Rows
Insured #1
Insured #2
Amount of Coverage Desired
Type of Coverage Desired (Term, Universal, Whole Life)
Additional information, request for coverages, or questions
*
if none, please Type NONE
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Flood Insurance
Through NFIP or Private Markets
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
Risk Information (most of the structure information we will attain via the County Appraisers website)
*
Rows
Occupancy?
Primary Residence?
Vacation Home?
Rented to Others?
Required for Closing?
Flood Elevation Certificate
Property #1
Residential
Single Family
2-4 Family (Apt)
Condo Unit Owner
Mobile Home
Small Business
YES
NO
YES
NO
YES
NO
YES
NO
I have (attach below)
I have ordered
I do not have
Attach Flood Elevation Certificate here
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Contact Information for Lender (Lender Name, Processor Name, Tel #, Email)
*
Type NONE, if none.
Additional information, request for coverages, or questions
*
if none, please Type NONE
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If your choice was not listed, please let us know what insurance type you are looking for. Otherwise, please select Submit below.
Thank you!
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