The Murray Insurance Agency Quote Request

1
Contact Information
First Name
Last Name
2
Phone Number
Please enter a valid phone number.
3
Email
example@example.com
4
Birthdate
Month
Day
Year
5
Social Security NumberOptional but will ensure a more accurate quote
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6
Driver's License Number
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7
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
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Cape Verde
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Chile
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Christmas Island
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Cote d'Ivoire
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Cuba
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The Gambia
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Laos
Latvia
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Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
Are you married?
YESNO
9
Spouse's Name
First Name
Last Name
10
Spouse's Birthdate
Month
Day
Year
11
Spouse's Social Security NumberOptional but will ensure a more accurate quote
Protected using 256 bit SSL (Secure Socket Layer) connection that uses a SHA256 Certificate. Submissions are encrypted.
12
Driver's License Number
Protected using 256 bit SSL (Secure Socket Layer) connection that uses a SHA256 Certificate. Submissions are encrypted.
13
What kind of insurance do you need?* This field is required.Select all that apply
Auto
Home & Contents
Motorcycle / ATV
Boat
Motor Home
Farm & Ranch
Business
Life & Health
14
Vehicle Information
15
What type of coverage would you like?
Liability Only
Liability Only
Liability w/ Comp and Collision
16
List Any Additional Drivers
17
List any accidents, violations or claims from the last 5 years
18
Do you currently have auto insurance?
YESNO
19
Home InformationSelect what best describes you
I do not own my home. I am a renter.
I own my home and live in my home.
I own my home but rent it to others.
20
Is the address the same as the mailing address?(entered previously)
YESNO
21
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
22
Home informationIf this is not applicable to you just click next!
How many acres is the property?
Please Select
Please Select
Shingle
Metal
Other
What type of roof do you have?
How many square feet is the home?
What year was the roof last replaced?
23
Do you have any pets?
YESNO
24
How many pets? What breed/kind?
25
Do you have any of these:
Trampoline
Pool
ATV
Business on Property
26
Is this for a new home purchase?
YESNO
27
What is/was the purchase or closing date?
Date
Month
Day
Year
28
Do you currently have home insurance?
YESNO
29
List any previous home insurance claims
30
Motorcycle / ATV Information* This field is required.
31
What type of coverage would you like?
Liability Only
Liability Only
Liability w/ Comp and Collision
32
Who will be operating the motorcycle / ATV?* This field is required.
33
Boat Information
Year
Make/Model
Length
Cost New
Please Select
Please Select
Fiberglass
Metal
Wood
Other
Body Type
Please Select
Please Select
Inboard
Outboard
Inboard-Outdrive
Motor Type
Horsepower
Max Speed
34
Do you have another boat to add?
YESNO
35
Boat 2 Information
Year
Make/Model
Length
Cost New
Please Select
Please Select
Fiberglass
Metal
Wood
Other
Body Type
Please Select
Please Select
Inboard
Outboard
Inboard-Outdrive
Motor Type
Horsepower
Max Speed
36
What type of coverage would you like?
Liability Only
Liability Only
Liability w/ Comp and Collision
37
Who will be operating the boat?
38
Motor Home / Travel Trailer Information
Year
Make/Model
Length
Cost New
Please Select
Please Select
None
One
Two
Three
Four
Any Slide Outs?
Please Select
Please Select
Motor Home
Travel Trailer (Pull Behind)
Type?
Please Select
Please Select
Occasional Travel
Seasonal Home
Permanent Home
Primary Use
39
Do you have another Motor Home / Travel Trailer to Add?
YESNO
40
Motor Home / Travel Trailer 2 Information
Year
Make/Model
Length
Cost New
Please Select
Please Select
None
One
Two
Three
Four
Any Slide Outs?
Please Select
Please Select
Motor Home
Travel Trailer (Pull Behind)
Type?
Horsepower
Max Speed
41
What type of coverage would you like?
Liability Only
Liability Only
Liability w/ Comp and Collision
42
Farming InformationSelect all exposures that apply
Row Crop
Hired Workers / Employees
Livestock
Hobby Farming
Farm Equipment
Property Leased to Others
43
Farming Locations
44
Due to the varied needs and dynamic options for farm policies, one of our Farm Insurance Specialists will reach out to you to find the best insurance to fit your needs.
45
Business Information
Business Name
Type of Business (or description of what you do)
Years in Business (or experience for new ventures)
Amount of Annual Payroll (excluding owner/partners)
46
What type(s) of insurance will you need?Select all that apply
General Liability
Property / Building
Business Auto
Worker's Comp
Tools / Equipment
Other
47
Due to the varied needs and dynamic options for commercial insurance policies, one of our Commercial Insurance Managers will reach out to you to find the best insurance to fit your needs.
48
Are you interested in a Life Insurance Quote?
YESNO
49
Life Insurance Questionnaire
Name of Insured
Birthdate
Please Select
Please Select
Yes
No
Do you smoke?
Weight
Height
Please Select
Please Select
Yes
No
Do you take medications for any ongoing medical conditions?
50
Life Insurance Questionnaire (continued)
Please Select
Please Select
Term
Whole
What type of Life Insurance are you interested in?
Please Select
Please Select
100K
150K
250K
500K
Other
Limit
Please Select
Please Select
10 year
15 year
20 year
25 year
30 year
Term Length
51
Would you like a life insurance quote for another individual?
YESNO
52
Life Insurance Questionnaire
Name of Insured
Birthdate
Please Select
Please Select
Yes
No
Do you smoke?
Weight
Height
Please Select
Please Select
Yes
No
Do you take medications for any ongoing medical conditions?
53
Life Insurance Questionnaire (continued)
Please Select
Please Select
Term
Whole
What type of Life Insurance are you interested in?
Please Select
Please Select
100K
150K
250K
500K
Other
Limit
Please Select
Please Select
10 year
15 year
20 year
25 year
30 year
Term Length
54
Are you interested in any of these?Select all that apply
Medical
Dental
Medicare
Vision
MedSup / Medicare Advantage
Travel Insurance
55
Due to the varied needs and dynamic options for health Insurance, a health insurance agent will reach out to you to find the best insurance to fit your needs.
56
Are you interested in Umbrella Insurance?An umbrella insurance policy extends well beyond your home and auto insurance. You’ll have the flexibility to select a liability limit that best protects your assets.You may also be covered for the following:-Personal injury coverage: for claims of libel, slander, defamation of character and more-Worldwide coverage: for incidents that happen abroad-Vacation rental liability: protection for accidents involving boats, jet skis, scooters and other rentals-Defense coverage: for legal fees and court costs
YESNO
57
How did you hear about the Murray Insurance Agency?
Current Client
Previous Client
Referral
Internet Search
58
Is there anything else you would like to let us know? Here's your chance!
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Large
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Small
Ok
Ok
59
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