IIP Insurance Agency_04-0217-00_Auto & Home Insurance Quote

Auto & Home Insurance Quote

IIP Insurance Agency
Please provide as little or as much information as you feel comfortable. We will contact you to fill in any important additional information.
Full Name 1:

First NameLast Name
Date of Birth:
Social Security #:
Driver’s License #:
Marital Status:
Occupation:
Phone Number:
Please enter a valid phone number.
Email:
example@example.com
Co-App Full Name 2:

First NameLast Name
Date of Birth:
Social Security #:
Driver’s License #:
Marital Status:
Occupation:
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physical Address (if different from above):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HOME INSURANCE INFORMATION
County:
Own or Rent Home:
Fire Dept. & Miles to Fire Dept.
Feet to Hydrant:
Current Insurance Carrier:
Requested Eff Date:
Dwelling Information
Year Built:
Purchase Date:
Market Value:
# of Families:
Square Feet:
Construction Type:
# of Stories/Style:
Type of Foundation:
Basement____%?
Finished____%?
Crawlspace____%?
Slab___%?
Garage(s):

AttachedDetachedBuilt InN/A
# of Cars or Square Feet:
# of Bathrooms - Full
# of Bathrooms - 3/4
# of Bathrooms - 1/2
# of Fireplaces - Wood
# of Fireplaces - Gas
# of Fireplaces - Electric
Wood/Corn Pellet Stove
Exterior:
Brick____%?
Brick Veneer____%?
Vinyl____%?
Wood____%?
Other Type____%?
Age & Type:
Roof:
Plumbing:
Electrical:
Heating:
Central or Window A/C:
Porch Type & Size:
Deck Type & Size:
# & Breed of Pets
Check if Applicable:

GazeboTrampolinePoolShedHot Tub
Other Exterior Features:
Coverages
Dwelling:$
Liability:$
Med Pay:$
Deductible:$
Optional Coverage (Water Back-Up, Earthquake, Mine Subsidence, Jewelry/Guns, etc.):
Prior Claims

List Prior Claims:

Rows	Date:	Type:	Amount Paid:	Damages Repaired?
Claim:
Claim:
Claim:
Claim:

AUTO INSURANCE INFORMATION
Additional Licensed Household Members
Vehicle Information (Please list all vehicles, click "add a vehicle" to add more.)
Vehicle Coverages (Please list coverage's for all vehicles, click "add a vehicle" to add more.)
Liability Limits: BI/PD (100/300/100):
Tickets, Accidents or License Suspensions in past 5 years (Date, Type of Incident, Amount Paid & Explanation):
Please verify that you are human*
Should be Empty: