New Quote Request

Please select the agent on our team that you are working with or were referred to: *

Please let us know how you heard about us?

Please let us know how you heard about us?*

What is the name of the person who referred you?

Your Name*

First NameLast Name

Phone Number

Email

example@example.com

Please select the type of insurance quotes that we can help you with. The more lines of business you have the better deal we can get you! Select all that apply:

Address*

Street Address

Street Address Line 2

CityState

Zip Code

What is your date of birth*

Are you married?*

YesNo

What is your spouses name? *

First NameLast Name

What is your spouses birthday? *

Please list your units:

	Year	Make	Model	VIN	Value	Length	Type	Use	Pull type
1
2

Liability coverage for your trailer automatically covered by the vehicle that is pulling it. You do not need to, nor can you add liability only coverage to a trailer.

Physical damage coverage for your trailer is NOT covered by the vehicle pulling it, in order for damage to the trailer to be covered it must have coverage of it's own providing physical damage coverage. If you have a loan on your unit they typically require you to have this coverage, even if you don’t we recommend that you add it if the value is substantial. Typical deductibles are $500 - $1000. What would you prefer?

$500 deductible for physical damage$1000 deductible for physical damageNo coverage for physical damage

You can also add coverage to your trailer policy for all of the personal property inside of the trailer like clothing, camping gear, kitchen stuff, whatever personal items you keep in the trailer. How much coverage if any would you like to add for your personal property in the trailer?

Please list your units:

	Year	Make	Model	Hull ID #	Hull material	Length	# of engines	Engine type	HP per engine	Max Speed	Fuel Type	# of months used per year	Full Coverage	Liability Only	Has damage	Has protective devices	Value	Storage / Lay up location
1
2

Transport trailers can be covered as well. Please list them if you would like coverage:

	Year	Make	Model	VIN	Value	Length
1
2

Please list all drivers of the units listed above:

	Full Name	Date of birth	Drivers license #	Year of experience driving watercraft	Has tickets or accidents in the last 3 years	Safety Course
1
2

Are any of the watercraft used in any stunts, speed contests, or for racing

NoYes

Are any of the watercraft used as a residence or for business purposes?

NoYes

Are any of the watercraft under construction, designed or modified for competition, or hauled on a trailer not specifically manufactured as a boat trailer?

NoYes

Does the watercraft have any of the following protective devices?

Where are your watercraft stored when not in use?

My primary residenceSomewhere else

Do you live within 150 miles of the watercraft mooring/storage location?

YesNoOther

Address of mooring or storage location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How are your watercraft stored at this location?

Please list your units:

	Year	Make	Model	VIN	Engine Size in CCs	Turbo or Supercharged	Licensed for on road usage	Purchase Price	Value of after market equipment	Layup period in months	Stored in a locked structure?	Full Coverage	Liability Only	Anti Lock Breaks	Seat Belts	Theft Prevention	Helmet	Brake Light
1
2
3
4
5

Transport trailers can be covered as well. Please list them if you would like coverage:

	Year	Make	Model	VIN	Value	Length
1
2
3

Please list all drivers of the units listed above:

	Full Name	Date of birth	Drivers license #	Year of experience driving ATVs	Has tickets or accidents in the last 3 years	Motorcycle endorsement on DL	Safety Course
1
2
3
4
5

What insurance company and plan are you currently covered by?

Please email a copy of your current policy and a 5 year loss run report to sales@jessedryeragency.com and then we will follow up with questions. Without these two items we can not offer a quote. These two documents can be obtained from your current insurance carrier.

What is the name of your business?

What is the physical address of your business?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is your business one of the following?

Please select the types of coverages your business needs. Select all that apply.

How many individual units are there?

How many separate buildings are there?

How many board members are there if applicable?

Please list any licenses or designations required by your profession that you hold:

Please list the busienss name and type of business for all tenants:

Annual food sales

Annual liquor sales

What is the public square footage of your restaurant? (only include areas where customers can go)

What is the seating capacity?

How much coverage do you need for perishable goods if the power goes out?

Is your restaurant a franchise?

NoYes

Please select all that are present in your restaurant

Multiple TVsDance FloorSecurity GuardsVideo Games / Arcade

How many service bays do you have?

How many lifts do you have?

How many vehicles do you have left overnight at your location on average?

What is the average value of the vehicles left at your location overnight?

How much coverage would you like for tools and equipment owned by the business?

How much coverage would you like for tools owned by your employees?

How much coverage do you need for other property in your busienss like parts, furniture, office equipment, computers, ect?

Does your busienss do work on any of the following items?

Used tiresHeavy equipmentMotorhomes or travel trailersATVs, OHVs, Side by Sides, Boats, Motorcycles

Please describe in as much detail as possible what the business does. The more detailed the better. *

When did the business start operations?

Date

What type of legal entity is the business?

What is the business's EIN or Tax ID number?

What is the business's gross annual revenue. If new please estimate.

How many employees does the business have, not including owners?

What is the annual payroll for all employees?

What is the annual payroll for all owners?

Please describe the equipment you need covered as well as the cost to replace it:

What year was your building built?

What is the total building square footage?

How many individual units does the building consist of?

Please list any other business that share your building if applicable:

What percentage of the building is vacant?

What type of roof is on the building?

Have any of the following systems on your building been updated?

	All original	Partially replaced	Totally replaced in year:
Roof
Electrical
Plumbing
Heating

Is the entire building sprinklered?

NoYes

Are there any security systems on the building?

Alarm that calls out if triggeredLocal alarmVideo surveillanceOther

Please list your vehicles

	Year	Make	Model	VIN #	Liability Only	Full Coverage	Value	Permanently Mounted Equipment
1
2
3
4
5
6
7
8
9
10

Please list your all employees that will drive the vehicles:

	Full Name	Date of Birth	Drivers License #	Drivers License State	Marital Status
1
2
3
4
5
6
7
8
9
10

What is the furthest distance in miles that any of your vehicles will travel for work?

What company is your current business insurance with?

How much are they charging you?

Have you had any claims? If so please let us know the dates and what happened.

Reguarding the other quote you need, please describe the type of insurance quote we can help you with:

How much do you think it would cost to replace all of your personal property inside the home you are renting? Clothes, furniture, ect

What year was the home you are renting built?

What type of home is your rental?

How many square feet is the home you are renting?

Do you have any special jewelery, firearms, electronics, or other expensive items that you are concerned about covering?

Do you have any dogs? If so what are the breeds?

Is the home a new purchase or do you already own it?

New purchaseAlready own it

What company is your home currently insured with?

How much are they charging you?

Please provide us with the name and contact info for your Realtor and Mortgage Lender if applicable so we can get them the documentation need for your closing:

What is your anticipated closing date on the new property?

Date

What is the occupancy of the home going to be?

Is the property a manufactured or modular home?

NoYes

Is the property a condo or townhome?

NoYes

Does the HOA's insurance cover the outside of the condo or townhome?

NoYes

What year was the house built?

What year was the roof on your home installed?

Do you have any solar panels?

NoYes

Do you have a fortified or impact resistant roof?

NoYes

Do you know what the total square footage is? (do not include any basement sq ft)

How many stories is the home?

What type of foundation does the home have? Select all that apply.

Concrete slabBasementCrawlspaceOther

What type of exterior finish is on home? Select all that apply.

Is any of the exterior finishing on the home damaged or is there any peeling paint?

NoYes

What type of material is the roof covering made of? Select all that apply.

On the roof is there any damage, missing shingles, or more than two layers of shingles?

NoYes

Are there any tree limbs or other vegetation touching the roof?

NoYes

Does the property have a garage or carport?

Attached garageDetached garageCarportNone

How many cars does the garage or carport hold?

Are the any detached structures on the property like detached garages, sheds, barns, or anything else?

NoYes

Please describe the detached structures, what they are, what they are used for, and what the square footage of each is.

Are all of the detached structures in "like new condition" with no exterior damage, peeling paint, or damage on the roof?

Yes they are all in like new conditionNo they are not all in like new condition and there is damage

What type of fuel does the primary heating system use?

Natural GasElectricityOther

Is there a pool or trampoline on the property?

NonePoolTrampoline

Is the part of the yard where the pool or trampoline is fenced?

YesNo

Do you have any dogs?

NoYes

What breed are your dogs?

Do you know if the roof, plumbing, electrical or heating on the property has been replaced?

They are all originalDon't knowYes some of that has been replaced

Please let us know what was replaced and what year.

Is there anything on the property that needs repaired?

NoYesI'm not sure

Can you please describe everything on the home that need repaired?

Will you have any sort of security devices on your home? Like an alarm, or video doorbell?

Yes I have a security system that is professionally monitored (calls out to emergency services)Yes I have a locally monitored alarm or camera system (ex: Ring or Nest Doorbell)None

Will you have a Wi-Fi enabled smart thermostat or water leak sensors on the home?

NoneSmart ThermostatWater Leak Sensor

We have some discounts that you can get based on education, does anyone in your household have a high school, bachelors, or graduate degree?

High School GraduateBachelors DegreeGraduate Degree

What do the members of your household do for work? We have some occupational discounts, and if you are eligible we will add them for you.

I am going to try to get you the best price possible on this quote, because the cost of your Homeowners Insurance will get built directly into your monthly mortgage payment.

That means every dollar that we can save on your Homeowners Insurance policy will lower your mortgage payment, and everyone want's a lower mortgage payment, right!

The best way to save on your Homeowenrs Insurance is to bundle your Auto Insurance with the same company.

What kind of vehicles do you own?

Tell us about your vehicles

	Year	Make	Model	VIN	Annual Mileage	Usage	Parking	Ownership Status
1
2
3
4
5
6

Please list all individuals that drive your vehicles regularly or frequently.

	Full Name	Birthday	Drivers License #	Has tickets or accidents in the last 3 years
1
2
3
4
5

What company are your vehicles currently insured with and how much are they charging you?

Next let's talk about some of the discounts that are available on our auto policies. We'll try to get as many as we can for you.

Do you currently own or rent your home? Either way bundling your home and auto insurance is the largest auto insurance discount available so we will take a look at that for you also!

We have some discounts that you can get based on education, does anyone in your household have a high school, bachelors, or graduate degree?

High School GraduateBachelors DegreeGraduate Degree

We have special Home and Auto discoutns for all: Active and Retired Military Personel, Teachers, Law Enforcement, Firefighters, Nurse(RN), Doctors, Lawyers, Librarians, Engineers, CPA/CFP, Scientests, Architects, and Pilots.

Or anyone that is retired from one of these places.

What do the members of your household do for work?

If any of your drivers are students what is their current GPA?

Do you have a smart phone that you can download our safe driving app on? It can save you up to 20% by having the app on all your drivers smart phones.

YesNo

Do you have any trailers, motorcycles, ATVs, boats, motorhomes, campers or any other fun stuff like that? We have discounts for all of those items!

Yes I have someNo I don't have any

Please list your units:

	Year	Make	Model	VIN	Engine Size in CCs	Turbo or Supercharged	Licensed for on road usage	Purchase Price	Value of after market equipment	Layup period in months	Stored in a locked structure?	Full Coverage	Liability Only	Anti Lock Breaks	Seat Belts	Theft Prevention	Helmet	Brake Light
1
2
3
4
5

Transport trailers can be covered as well. Please list them if you would like coverage:

	Year	Make	Model	VIN	Value	Length
1
2
3

Please list all drivers of the units listed above:

	Full Name	Date of birth	Drivers license #	Year of experience driving ATVs	Has tickets or accidents in the last 3 years	Motorcycle endorsement on DL	Safety Course
1
2
3
4
5

In this next section you will pick out the coverages you would like on your auto insurance policy. Our goal is to make sure you understand how your policy works and make sure that if you have a claim there are no surprises.

The first coverage on your policy is Liability which pays if you hurt someone else in an accident, and is what we consider the most important coverage you can have on your policy. With liability, you're actually able to pick how much protection you have and a general rule is that you always want to have at least as much coverage as what your assets are worth. A lot of people don’t know that if they caused an accident where the cost of the damages is more than the amount you are covered for, you can be sued for the rest.

Unfortunately, if you get sued because of an accident the courts and lawyers can really wipe you out. They can potentially take any away your entire net worth including any real estate you own, your vehicles, all the money you have in the bank, and even garnish up to 25% of your furture income.

That's why we say liability is the most important part of your policy, because without the right amount of coverage your assets may be left exposed in a lawsuit. If you were to add all of those things up, your home equity, vehicles, life savings, and future income what do you estimated the total value be?

Total Assets / Net Worth that you want protected if you are in a lawsuit after a car accident:

Uninsured and Underinsured Motorist Bodily Injury coverage pays for your medical bills and time off work, if you are injured in an accident caused by someone who does not have insurance. Some customers choose to leave this off if they are already covered with good health insurance and disability coverage. But, if you don't have those things and would want your auto insurance policy to pay if that happens, we can add it. What do you think makes sense for you?

Medical Coverage pays medical bills for you and anyone riding in your vehicle if they are injured. Even if it's a simple accident like crashing in snow or hitting a deer and it was no one's fault this coverage still pays out. This is another one where you get to pick how much protection you want. Would you prefer:

The next coverage is what people often refer to as "full coverage" What that means in insurance terms is collision coverage, which pays for your vehicle if you are in an accident. And, comprehensive coverage which pays for damage to your vehicle as a result of anything other than an accident, like fire, theft, vandalism, and things like that. If you have a loan on your vehicle this is required, but even if you don't we still recommend it unless you are comfortable replacing the vehicle on your own, if you are in an accident. Would you be more comfortable with a $1,000 or $500 deductible?

Another really important thing on this topic is the kind of parts that you want us to use on your vehicle if you have a claim. All insurance companies try to use aftermarket or salvaged parts to save money, but if this would upset you, we can add the OEM parts endorsement, which guarantees that we will only use Original Manufacturer Equipment on your vehicle. Is that something you would like?

The next coverage is rental car reimbursement. A lot of customers don’t realize that if you have a claim, your insurance does not automatically pay for you to have rental car. If you have an extra vehicle, or don't mind paying for your own rental car you can leave it off and save a few dollars. But, if you would want us to take care of it for you we can add it. What do you prefer?

Another thing that a lot of our customers want is GAP or New Car Replacement Coverage. What that does is make sure that we pay off your loan even if the balance is higher than the value of your vehicle at the time of an accident. Or, if you have a vehicle that is only a few years old it pays to buy you another brand new one. Is that something that you would like us to do if you have an accident?

Have you or anyone else that is a drive on your policy have any tickets or accidents in the last 5 years or have an SR-22 requirement?

Reguarding the ticket, accident, or SR22 please share more details on know who, what, and when

Ok, to wrap up we like to ask everyone what their priority is so that we know what's important to you? Do you want the best coverage, the lowest price, or something in the middle?

Who do you want your beneficiary to be? *

First NameLast Name

What is the relationship between the person the quote is for and the beneficiary? *

Is this quote for someone under 18 years old?

NoYes

What is your drivers license number?*

What is your social security number?*

What is your occupation and employers name?*

What is your approximate annual income?*

Height?*

Weigh?*

Who is your primary care physician? *

City and state where primary care physician is located?*

What is the child's full name, birthday, and social? *

Did the child have any birth defects or health issues at birth?*

Please list the Fathers full name, date of birth, and address, drivers license #, current life insurance coverage amount, and annual income: *

Please list the Mothers full name, date of birth, and address, drivers license #, current life insurance coverage amount, and annual income:*

Who will be the policy owner? If different than the parents we need the owners name, DOB, address, drivers license number, and annual income. *

Who will be the beneficiary? If different than the parents we need the beneficiary's name, relationship to the insured, address, and phone number. *

What is the combined annual income of the child's parents?

How many siblings does the child have?*

Do any of the siblings have any birth defects?*

Do all of the other siblings have Life Insurance?*

We have two options available for your Life Insurance Quote.

Option one is a fully underwritten quote. This allows us to offer you a larger coverage amount and more policy options. But it also requires that we schedule a health screening appointment with one of our nurses to check your blood pressure, cholesterol, and test for nicotine usage. The appointment is free and only takes about 20 minutes. We can schedule the appointment in the nurse's office, at your home, or they can even come to you at work.
Option two is an automated underwriting quote. This option does not require a physical appointment and just goes off of your medical records. With this option coverage is available up to $150,000 per person.

Would you like to have a fully underwritten quote with the free medical screening that allows for higher coverage limits and additional options, or do the quote with no medical screening that allows for coverage up to $150,000?

Fully underwritten quoteAutomated quote

Please list 2-3 dates and times that would work to schedule the free medical screening*

Have you, in the past five years, used Tobacco or Nicotine products in any form (e.g. cigarettes, pipes, cigars, snuff, chewing tobacco or nicotine delivery device such as gum or patch, etc.)?*

YesNo

If yes: please let us now when the last time you used a tobacco or nicotine product was, what types of products you use, and how long you have used them?

Do you use recreational Marijuana? (It's legal so it's ok to say yes if you do, and it does not prevent you from being covered)*

YesNo

Have you, in the past five years, been admitted or advised to be admitted to any hospital or health care facility; or undergone or been advised to have surgery, biopsies, treatment or medical test?*

YesNo

If yes: where, what for, and what was the result or outcome?

Have you, in the past five years, been diagnosed by a member of the medicalprofession for any illness, disease, or injury?*

YesNo

If yes: what was the diagnosis, when was the diagnosis, who was the doctor that diagnosed you, and if you are taking prescriptions for it we need the name and dosage?

Have you, in the past five years, been prescribed any prescription medication by a member of the medical profession for any illness, disease, condition, or injury?*

YesNo

If yes: we need to know the name, dosage, and how often you take the prescription. What condition was the prescription written for, who the prescribing doctor was, how long you have been taking it, and when did you stop taking it or are you still taking it?

Have you, in the past five years, been disabled, received disability income benefits, or been unable to work or perform and carry out your normal daily functions for any reason other than maternity leave or recovery from minor surgery?*

YesNo

If yes: when, why, and is it an ongoing issue?

Have you ever been treated for, drug or alcohol addition?*

YesNo

If yes: when, where, and what for?

Have you ever attempted suicide?*

YesNo

If yes: when and did you receive treatment?

Have you, in the past 10 years, had your driver’s license suspended, revoked, pled guilty to, or been convicted of reckless driving, or driving under the influence (DUI/DWI)?*

YesNo

If yes: when, where, and what was the ticket written for?

Have you, in the past 10 years, pled guilty to or been convicted of a felony or misdemeanor, or are such charges pending against you, or are you currently on parole or probation?*

YesNo

If yes: when, where, and what was the charge, what was the conviction, if on parole or probation when does it end?

Have you had an application for life, accident, or health insurance, or reinstatement of a policy, declined, postponed, cancelled, or issued other than as applied for?*

YesNo

If yes: when, what company, and why was it declined?

Are you a member of the military, military reserve or National Guard (active or inactive) or do you have a written agreement to become a member at a future date?*

YesNo

If yes: what branch, what is your enlistment date, what is your anticipated discharge date? Have you been alerted or received orders for duty outside the US?

Are you currently receiving, or within the next two years do you expect to receive, hazardous duty or incentive pay?*

YesNo

If yes: what are your job duties, where will they be performed, when will they be performed?

Within the next two years, do you plan to work or reside outside the US?*

YesNo

If yes: when, where, how long, and what is the reason?

Have you, in the past two years, flown as a student pilot, pilot or crewmember (or do you plan to within the next two years)?*

YesNo

Have you, in the past two years, or do you plan to in the next two years, take part in hang gliding, para sailing, para kiting, parachuting, skydiving, ultralight, soaring, ballooning, bungee jumping, rock or mountain climbing, organized racing by automobile, motorcycle, powerboat or snowmobile, or underwater diving?*

YesNo

Within the past 90 days have you been unable to perform the normal duties of his/her occupation for 15 or more working days because of health reasons?*

YesNo

If yes: when, why, and is it an ongoing issue?

Do you have another person that you would like a quote on?*

YesNo

What is the name of the second person who you need a quote on?*

First NameLast Name

Who would you like to be this person's beneficiary?

First NameLast Name

What is the second person's your birthday?*

What is the second person's drivers license number?*

What is the second person's social security number?*

What does the second person do for work, and what is their employers name?*

What is the second person's approximate annual income?*

How tall are you?*

How much do you weigh?*

Who is your primary care physician? *

What city and state is your primary care physician located in?*

Have you, in the past five years, used Tobacco or Nicotine products in any form (e.g. cigarettes, pipes, cigars, snuff, chewing tobacco or nicotine delivery device such as gum or patch, etc.)?*

YesNo

If yes: please let us now when the last time you used a tobacco or nicotine product was, what types of products you use, and how long you have used them?

Do you use recreational Marijuana? (It's legal so it's ok to say yes if you do, and it does not prevent you from being covered)*

YesNo

Have you, in the past five years, been admitted or advised to be admitted to any hospital or health care facility; or undergone or been advised to have surgery, biopsies, treatment or medical test?*

YesNo

If yes: where, what for, and what was the result or outcome?

Have you, in the past five years, been diagnosed by a member of the medicalprofession for any illness, disease, or injury?*

YesNo

If yes: what was the diagnosis, when was the diagnosis, who was the doctor that diagnosed you, and if you are taking prescriptions for it we need the name and dosage?

Have you, in the past five years, been prescribed any prescription medication by a member of the medical profession for any illness, disease, condition, or injury?*

YesNo

If yes: we need to know the name, dosage, and how often you take the prescription. What condition was the prescription written for, who the prescribing doctor was, how long you have been taking it, and when did you stop taking it or are you still taking it?

Have you, in the past five years, been disabled, received disability income benefits, or been unable to work or perform and carry out your normal daily functions for any reason other than maternity leave or recovery from minor surgery?*

YesNo

If yes: when, why, and is it an ongoing issue?

Have you ever been treated for, drug or alcohol addition?*

YesNo

If yes: when, where, and what for?

Have you ever attempted suicide?*

YesNo

If yes: when and did you receive treatment?

Have you, in the past 10 years, had your driver’s license suspended, revoked, pled guilty to, or been convicted of reckless driving, or driving under the influence (DUI/DWI)?*

YesNo

If yes: when, where, and what was the ticket written for?

Have you, in the past 10 years, pled guilty to or been convicted of a felony or misdemeanor, or are such charges pending against you, or are you currently on parole or probation?*

YesNo

If yes: when, where, and what was the charge, what was the conviction, if on parole or probation when does it end?

Have you had an application for life, accident, or health insurance, or reinstatement of a policy, declined, postponed, cancelled, or issued other than as applied for?*

YesNo

If yes: when, what company, and why was it declined?

Are you a member of the military, military reserve or National Guard (active or inactive) or do you have a written agreement to become a member at a future date?*

YesNo

If yes: what branch, what is your enlistment date, what is your anticipated discharge date? Have you been alerted or received orders for duty outside the US?

Are you currently receiving, or within the next two years do you expect to receive, hazardous duty or incentive pay?*

YesNo

If yes: what are your job duties, where will they be performed, when will they be performed?

Within the next two years, do you plan to work or reside outside the US?*

YesNo

If yes: when, where, how long, and what is the reason?

Have you, in the past two years, flown as a student pilot, pilot or crewmember (or do you plan to within the next two years)?*

YesNo

Have you, in the past two years, or do you plan to in the next two years, take part in hang gliding, para sailing, para kiting, parachuting, skydiving, ultralight, soaring, ballooning, bungee jumping, rock or mountain climbing, organized racing by automobile, motorcycle, powerboat or snowmobile, or underwater diving?*

YesNo

Within the past 90 days have you been unable to perform the normal duties of his/her occupation for 15 or more working days because of health reasons?*

YesNo

If yes: when, why, and is it an ongoing issue?

If you have any additional request or notes please add them here:

By submitting this form you are requesting to be contacted by our team reguarding insurance products, as well as giving permission for them to call, text, email, and mail you reguarding insurance products. We look forward to speaking to you!

New Quote Request

Travel, Utility, or Livestock Trailer Insurance

Boat or Jet Ski Insurance

ATV, OHV, Dirt Bike, Side by Side Insurance

Health / Medicare Insurance

Business Insurance

HOA, Townhome, Condos or Apartment Complex Insurance

Contractor

Commercial Building Landlord

Restaurant

Auto Service / Auto Repair

Other quote request

Renters Insurance

Homeowners Insurance

Auto Insurance

Life Insurance

Please answer the personal and medical questions below for the second person you would like a Life Insurance quote on: