Insurance Quote Request
Complete this form as accurately as possible and I will be in touch within 48 hours to go over what I found. Thank you!
Insured Name
*
First Name
Last Name
Cell Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Driver's License number
Gender
*
Please Select
Male
Female
N/A
Marital Status
*
Please Select
Married
Single
Divorced
Widowed
Highest Education Level
*
Please Select
High School Degree
GED
Some College
Associate/Technical Degree
Bachelors Degree
Masters Degree
Doctorate Degree
None
Occupation
*
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Spouse Information:
Complete all fields. If you’re not married, continue to the next page.
Spouse Name
First Name
Last Name
Spouse Date of Birth
-
Month
-
Day
Year
Date
Spouse Driver's License number
Spouse Highest Education Level
Please Select
High School Degree
GED
Some College
Associate/Technical Degree
Bachelors Degree
Masters Degree
Doctorate Degree
None
Occupation
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Current Auto Policy:
Do you want an auto insurance quote?
*
Please Select
Yes
No
Who is your current carrier
What is your current policy term
Annual
Six months
What are you currently paying?
If you don't know the exact amount, please provide best estimate either monthly or annually
When does your current policy expire?
If you don't know the exact date, please provide the best estimate
How long have you been with your current carrier?
Please Select
Less than 1 year
1-3 years
3-5 years
5 years or more
What is your current liability coverages?
Please Select
State minimums
50/100
100/300
250/500
CSL
I don't know, recommend for me
What is your current property damage coverage?
Please Select
25,000
50,000
100,000
250,000
500,000
I don't know, recommend for me
What is your current uninsured/underinsured motorist coverages?
Please Select
State minimums
50/100
100/300
250/500
I reject this coverage
I don't know, recommend for me
What is your current uninsured/underinsured motorist property damage coverage?
Please Select
25,000
50,000
100,000
250,000
I reject this coverage
I don't know, recommend for me
What is your current PIP or Medical payments coverage?
Please Select
2500
5000
10,000
Greater
I reject this coverage
I don't know, recommend for me
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Other Drivers:
Please include all drivers in your household
Additional Driver #1:
Additional Driver #2:
Additional Driver #3:
Additional Driver #4:
Do you have more than 4 additional drivers? If so, please list the rest below.
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Vehicles:
Please include all vehicles in your household
Vehicle #1
Vehicle #2
Vehicle #3
Vehicle #4
Are there more than 4 vehicles? If so, please list the rest below.
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Current Home Policy:
Do you want a homeowners or renters insurance quote?
*
Please Select
Yes, homeowners
Yes, renters
No
Do you own your home or rent?
Which best describes your home?
Please Select
Single-family home
Apartment
Townhome
Duplex
Mobile home
Who is your current carrier?
What are you currently paying annually?
If you don't know the exact amount, please provide best estimate
Is your home insurance paid through escrow or do you pay it?
When does your current policy expire?
If you don't know the exact date, please provide the best estimate
How long have you been with your current carrier?
Please Select
Less than 1 year
1-3 years
3-5 years
5 years or more
What is the value of your home or coverage amount needed?
What are your current deductibles?
Please Select
$500
$1000
$1500
$2500
1%
2%
I don't know, recommend for me
What is your current liability coverage?
Please Select
$100,000
$200,000
$300,000
$500,000
Greater than $500,000
I don't know, recommend for me
What are your current medical payments?
Please Select
$1000
$2000
$3000
$5000
$10,000
I don't know, recommend for me
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Home Details:
For the most accurate rates, please provide the most current details on your home
Year Built
Square Footage (Length x Width for mobile home)
Number of stories
How many acres?
Closest Water Hydrant
Please Select
Less than 500 feet
500-1000 feet
Greater than 1000 feet
Closest Fire Station
Please Select
0-5 miles
Greater than 5 miles
Fireplace
Please Select
Gas
Wood
None
Garage/Carport
Please Select
Attached 2 car garage
Attached 3 car garage
Attached 4 car garage
Not attached 2 car garage
Not attached 3 car garage
Carport
Number of bedrooms
Number of bathrooms
Foundation type
Exterior type
Roof Type
Year of update:
Swimming Pool
Please Select
Inground, no slide or diving board
Inground, with slide or diving board
Above ground
No pool
Trampoline
Please Select
Yes
No
Do you have any pets or animals? If so, please list the type, breed, and any history of incidents
Do you have any additional structures? If so, please describe
Do you have an alarm system?
Please Select
Yes, I pay for monitoring
Yes, I have local cameras
No
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Upload Current Policies:
If you have access to your current coverage pages, please upload them below in order for us to verify all information and coverages. You can also email them to kara@safe-harborins.com if that's easier.
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