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

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.Format: (000) 000-0000.

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):

# 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:

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):

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