Rise Insurance Ohio Quote Request Form

Rise Insurance Ohio Quote Request Form

Let's ensure you have the best protection plan for your needs at the most competitive price!
Select which quoting path you feel most comfortable with below:*

I will complete the full quoting form, including information on all household members, items I want covered, and details from my current policy declarations pages.I want a Rise professional to go through the quote form questions with me! This is done via phone or virtual meeting and will take 10-15 minutes of time if you have all of the data ready to go for the call.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
What is your preferred method of communication? We have communication that will regularly go out via text and email, but want to know the most preferred way to contact you in the event of an emergency.*

EmailTextPhone Call
How did you hear about Rise Insurance Ohio:*

I was referred by a friend / family memberI was referred by another industry professional (i.e. lender, realtor, financial advisor, etc.)Google SearchSocial Media Ad / PostI attended a KidsLinked EventCommunity Event with Rise as a sponsor (i.e. golf outing, charity walk/run, etc.)Learned about Rise through Rogue VolleyballOther
What type of coverage are you seeking? (select all that apply)*

Auto / MotorcycleHomeCondoRentersJewelry or High-Value ItemsBoatATV / UTV / Golfcart / Trailer / CamperPersonal Liability UmbrellaRental Property / Apartment BuildingSmall Business Coverage / General LiabilityCommercial Liability UmbrellaCommercial AutoDisability ProtectionLife Insurance
How many members are in your household? (count anyone that lives with you and should be covered by your policies!)*

1 - just me!234567More than 7
What is your birthdate?*
What is your driver's license number? *
Household Member 2 - Name*

First NameLast Name
Household Member 3 - Name*

First NameLast Name
Household Member 4 - Name*

First NameLast Name
Household Member 5 - Name*

First NameLast Name
Household Member 6 - Name*

First NameLast Name
Household Member 7 - Name*

First NameLast Name
Household Member 2 - Phone Number*
Please enter a valid phone number.
Household Member 3 - Phone Number*
Please enter a valid phone number.
Household Member 4 - Phone Number*
Please enter a valid phone number.
Household Member 5 - Phone Number*
Please enter a valid phone number.
Household Member 6 - Phone Number*
Please enter a valid phone number.
Household Member 7 - Phone Number*
Please enter a valid phone number.
Household Member 2 - Email*
example@example.com
Household Member 3 - Email*
example@example.com
Household Member 4 - Email*
example@example.com
Household Member 5 - Email*
example@example.com
Household Member 6 - Email*
example@example.com
Household Member 7 - Email*
example@example.com
Household Member 1 - What is your marital status?*

SingleMarriedDomestic PartnerWidowedDivorcedSeparated
Household Member 2 - What is your marital status?*

SingleMarriedDomestic PartnerWidowedDivorcedSeparated
Household Member 3 - What is your marital status?*

SingleMarriedDomestic PartnerWidowedDivorcedSeparated
Household Member 4 - What is your marital status?*

SingleMarriedDomestic PartnerWidowedDivorcedSeparated
Household Member 5 - What is your marital status?*

SingleMarriedDomestic PartnerWidowedDivorcedSeparated
Household Member 6 - What is your marital status?*

SingleMarriedDomestic PartnerWidowedDivorcedSeparated
Household Member 7 - What is your marital status?*

SingleMarriedDomestic PartnerWidowedDivorcedSeparated
Household Member 2 - What is your driver's license number? *
Household Member 3 - What is your driver's license number? *
Household Member 4 - What is your driver's license number? *
Household Member 5 - What is your driver's license number? *
Household Member 6 - What is your driver's license number? *
Household Member 7 - What is your driver's license number? *
Household Member 1 - What age were you originally licensed in the U.S.?*
Household Member 2 - What age were you originally licensed in the U.S.?*
Household Member 3 - What age were you originally licensed in the U.S.?*
Household Member 4 - What age were you originally licensed in the U.S.?*
Household Member 5 - What age were you originally licensed in the U.S.?*
Household Member 6 - What age were you originally licensed in the U.S.?*
Household Member 7 - What age were you originally licensed in the U.S.?*
Household Member 2 - What is your birthdate? *
Household Member 3- What is your birthdate? *
Household Member 4-What is your birthdate? *
Household Member 5- What is your birthdate? *
Household Member 6- What is your birthdate? *
Household Member 7- What is your birthdate? *
Household Member 1 - Social Security Number*
Please know our form is secure and your personal data is never public, nor is it ever shared.
Household Member 2 - Social Security Number*
Please know our form is secure and your personal data is never public, nor is it ever shared.
Household Member 3 - Social Security Number*
Please know our form is secure and your personal data is never public, nor is it ever shared.
Household Member 4 - Social Security Number*
Please know our form is secure and your personal data is never public, nor is it ever shared.
Household Member 5 - Social Security Number*
Please know our form is secure and your personal data is never public, nor is it ever shared.
Household Member 6 - Social Security Number*
Please know our form is secure and your personal data is never public, nor is it ever shared.
Household Member 7 - Social Security Number*
Please know our form is secure and your personal data is never public, nor is it ever shared.
Do you use any type of tobacco and/or nicotine products?*

YesNo
Household Member 1 - What is your occupation and job title?*
Some companies offer discounts based on your job field!
Household Member 2 - What is your occupation and job title?*
Some companies offer discounts based on your job field!
Household Member 3 - What is your occupation and job title?*
Some companies offer discounts based on your job field!
Household Member 4 - What is your occupation and job title?*
Some companies offer discounts based on your job field!
Household Member 5 - What is your occupation and job title?*
Some companies offer discounts based on your job field!
Household Member 6 - What is your occupation and job title?*
Some companies offer discounts based on your job field!
Household Member 7 - What is your occupation and job title?*
Some companies offer discounts based on your job field!
How long have you worked with your current employer?*
What is your total household income?*
Your auto and home-type policies protect your income from lawsuit, so let's make sure we're covering the correct amount!
Please share your current income - list your gross pay, which is the big number before taxes and benefits are taken out!*
Disability (paycheck protection) and Life insurance coverage has to be qualified for based on our individual income - this is important to know for quoting the correct amount of coverage for you!
Do you use any of your vehicles for Uber / Lyft / other delivery services?*

YesNo
Share with us which vehicle(s) you are using for Uber / Lyft / other delivery services:*
Share with us who primarily drives each vehicle in your household:*
Jordan drives the Chevy Malibu / Lyndsey drives the Honda Civic
Please list the details for any accident you or any household driver has had in the last 5 years - include the driver, date, who was at-fault, amount of loss payout, and if there were any injuries:*
Example: Suzie had a not at-fault in January 2020 - no injuries - not sure on the amount paid. OR List NONE if this does not apply to you.
Please list any tickets received by you or any household driver in the last 5 years - include the driver, date of ticket, and the reason the ticket was given:*
Example: Eric got a speeding ticket in March 2019 OR List NONE if this does not apply to you.
Have you or anyone in your household had their license suspended or revoked in the last 5 years?*

YesNo
How long have you had your Auto insurance with your current insurance company?*
How do you prefer to pay for your auto insurance?*

MonthlyAnnuallyI'm open to paying annually if the discount is large enough.I would like to see both options.
Most auto insurance companies offer a sizable discount for the use of telematics (app based monitoring of your driving habits). Are you interested in opting into this service?*

YesNo
How long have you had your Home insurance with your current insurance company?*
How do you prefer to pay for your homeowners insurance?*

MonthlyAnnuallyI'm open to paying annually if the discount is large enough.I would like to see both options.
How long have you been with your current Condo insurance provider? *
How do you prefer to pay for your condo insurance?*

MonthlyAnnuallyI'm open to paying annually if the discount is large enough.I would like to see both options.
How long have you had your Renters insurance policy with your current insurance company? *
How do you prefer to pay for your renters insurance?*

MonthlyAnnuallyI'm open to paying annually if the discount is large enough.I would like to see both options.
Year your home was built:*
Age of your roof:*
Is your home or condo part of a homeowners or condo association?*

YesNoI'm not sure
Please select the primary heating source for your home or condo:*

GasElectricOilSolid Fuel (i.e. wood / coal burning stove)
Do you have a wood burning stove in your home or condo?*

YesNo
Do you have a garage?*

YesNo
Is your garage:*

AttachedDetached
What size is your garage? List the number of cars:*
Do you have any pets?*

YesNo
Please share the type of each pet and their breed:*
Has your pet ever bitten anyone?*

YesNo
Is your home currently under construction?*

YesNo
Please briefly describe the type of construction happening at your home:*
Example: Kitchen Remodel
Is there a daycare or other business that is ran from your home?*

YesNo
Please tell us the purchase date and purchase price of your home or condo:*
Example: Home purchased June 2019 for $250K
How many rental properties / apartment buildings do you own?*

1234I own more than 4 properties
Property 1 - property address:*
Example: Home purchased June 2019 for $250K
Property 2 - property address:*
Example: Home purchased June 2019 for $250K
Property 3 - property address:*
Example: Home purchased June 2019 for $250K
Property 4 - property address:*
Example: Home purchased June 2019 for $250K
Property 1 - purchase date and purchase price:*
Example: Home purchased June 2019 for $250K
Property 2 - purchase date and purchase price:*
Example: Home purchased June 2019 for $250K
Property 3 - purchase date and purchase price:*
Example: Home purchased June 2019 for $250K
Property 4 - purchase date and purchase price:*
Example: Home purchased June 2019 for $250K
Property 1 - year home was built:*
Property 2 - year home was built:*
Property 3 - year home was built:*
Property 4 - year home was built:*
Property 1 - age of roof:*
Property 2 - age of roof:*
Property 3 - age of roof:*
Property 4 - age of roof:*
Property 1 - Please choose the current occupancy for your rental:*

Long-Term TenantShort-Term Tenant (rented on daily, weekly, or monthly basis)VacantUnder Construction
Property 2 - Please choose the current occupancy for your rental:*

Long-Term TenantShort-Term Tenant (rented on daily, weekly, or monthly basis)VacantUnder Construction
Property 3 - Please choose the current occupancy for your rental:*

Long-Term TenantShort-Term Tenant (rented on daily, weekly, or monthly basis)VacantUnder Construction
Property 4 - Please choose the current occupancy for your rental:*

Long-Term TenantShort-Term Tenant (rented on daily, weekly, or monthly basis)VacantUnder Construction
Share with us any and all updates that you are aware your home or condo has had. (Roof, HVAC, Electrical, Plumbing)*
Example: Roof replaced in 2017, HVAC replaced in 2015 OR list None
Property 1 - Share with us any and all updates that you are aware your home or condo has had. (Roof, HVAC, Electrical, Plumbing)*
Example: Roof replaced in 2017, HVAC replaced in 2015 OR list None
Property 2 - Share with us any and all updates that you are aware your home or condo has had. (Roof, HVAC, Electrical, Plumbing)*
Example: Roof replaced in 2017, HVAC replaced in 2015 OR list None
Property 3 - Share with us any and all updates that you are aware your home or condo has had. (Roof, HVAC, Electrical, Plumbing)*
Example: Roof replaced in 2017, HVAC replaced in 2015 OR list None
Property 4 - Share with us any and all updates that you are aware your home or condo has had. (Roof, HVAC, Electrical, Plumbing)*
Example: Roof replaced in 2017, HVAC replaced in 2015 OR list None
Please share if you have had any claims in the last 5 years - include date of loss, type of loss, amount paid for damages.*
Please share if you have had any claims in the last 5 years at your rental properties - include date of loss, type of loss, amount paid for damages, and list the address for the property that suffered the loss.*
Do you have any of the following at your apartment, condo or home:*

TrampolineSwimming PoolSolar PanelsNone
Please mark all security devices you have in your apartment, condo or home:*

Deadbolt LocksSmoke AlarmsFire ExtinguisherLocal Fire/Burglar AlarmCentral Fire/Burglar Alarm (Immediately contacts a third party)None
Do you or anyone in your household smoke?*

YesNo
How much personal property coverage do you want? This limit protects your clothes, furniture, electronics, personal items, etc.*
Suggested minimum: For Renters and Condo Owners: $20-25K/Person - For Homeowners: be sure to factor in all furnished rooms and items in a garage for your total!
How much coverage do you want to protect the interior structure of your condo? This limit protects the flooring, wall coverings, kitchen/bath fixtures and cabinetry, and anything that is physically attached to the interior of your condo. *
We recommend a minimum of 30% of your Condo's value. Example: A condo purchased for 150K would need a minimum of $30K in protection.
What deductible amount are you most comfortable paying if you suffer a loss? *
Example: Minimum for Renters and Condo is typically $500 and for Home is typically $1000
Do you have any jewelry or high value items you would like to insure?*

YesNo
Please provide a description of each jewelry/high value item you would like covered, the amount of coverage you want, and the month and year you purchased said item. *
Example: Engagement Ring: $3,500 cost, March 2020
Please share with us how much coverage you are seeking on your Personal Liability Umbrella:*
Umbrellas are offered in increments of $1,000,000 - We recommend a minimum of 5 times your annual household income PLUS any equity in your home/vehicles PLUS the amount in checking/savings/retirement accounts!
How much are you currently paying for your Umbrella coverage?*
Please list the year / make / model / VIN or serial number / value for any ATV / UTV / Golfcart / Trailer / Camper you would like quoted:*
Example: 2022 Coleman Outfiter 400 / 123WES456BHG789PL / $15,500
My ATV / UTV / Golfcart / Trailer is registered for road use:*

YesNo
Please list the year / make / model / serial number for your boat:*
Example: 2016 Sea Ray SPX 210 / 234RTY123JHG
Please share the length and Horse Power of your boat:*
Example: 22 feet and 150 HP
Please list the current value of your boat (cost to replace):*
Example: $27,000
Please select the hull type for your boat:*

Flat-bottom HullAll other Hull types
Please select the motor type for your boat:*

InboardOutboardIn/OutOther
Please list all bodies of water where you will regularly operate your boat:*
Example: Alum Creek, Lake Erie, Buckeye Lake, private lake/pond, etc.
I have completed a boat safety course in the last 3 years and can provide the certificate of completion:*

YesNo
Please attach a copy of your declaration pages below. Please include documents for each type of policy quote you are requesting. (Auto, Renters, Homeowners, Condo, etc.) OR you check out the additional link in your email for making this step easier!

Cancelof
Please attach an appraisal for each high value item that you want covered. (Must be less than three years old)

Cancelof
Let's get your initial quote conversation scheduled with our team of professionals! Please click on the calendar links below to schedule, then complete this question by marking who you were able to get scheduled with below:*

with Lyndsey - calendly.com/lyndseym-rise-inswith Jordan - calendly.com/jordan-rise-insI was unable to find a time that works with my schedule.
Let's get your initial quote conversation about your Business Insurance or Rental Property/Apartment Building coverage needs scheduled with our team of professionals. Please click on the calendar links below to schedule, then complete this question by marking who you were able to get scheduled with below:*

with Lyndsey - calendly.com/lyndseym-rise-inswith Jordan - calendly.com/jordan-rise-insI was unable to find a time that works with my schedule.
Please share where you have your current Disability Income Protection:*

I only have coverage through my employer benefitsI only have coverage that I own privately outside of workI have coverage both through my employer benefits and with a policy I purchased on my ownI do not have any Disability Income Protection
Please share where you have your current Life Insurance Protection:*

I only have coverage through my employer benefitsI only have coverage that I own privately outside of workI have coverage both through my employer benefits and with a policy I purchased on my ownI do not have any Life Insurance Protection
Have you ever been on a disability claim or been out of work due to injury or illness without coverage before?*

YesNo
Please select the range of coverage you are seeking for your Life Insurance Protection:*

up to $100,000$100,000 - $500,000$500,000 - $1,000,000more than $1,000,000I need help determining how much coverage I want in place
Please attach any policy information you have access to for your Disability Income and/or Life Insurance protection plans, including work benefits and privately owned coverage.

Cancelof
Should be Empty: