Millstone Insurance

1

Which Type of Coverage Do You Need?* This field is required.

Personal Insurance - Auto, Home, Boat, etc

Commercial Insurance

2

Personal and Family Coverage Quote

Auto Insurance

Homeowners Insurance (Home, Condo, Renters, Rental Property, Tenant, Cabin)

Recreational Vehicle Insurance (RV, Motorcycle, Boat, ATV)

Earthquake and/or Flood Insurance

Life Insurance

Umbrella Insurance

Other

3

Commercial Insurance Quote

Business Auto Insurance

Business Liability Insurance

Workers Comp Insurance

Landlord & Tenant Insurance

Business Personal Coverage Insurance

Umbrella Insurance

Other

4

Contact Information (PERSONAL AUTO)* This field is required.How can we contact you?

First Name

Last Name

Please enter your email

Please enter your phone

5

Your Address? (PERSONAL AUTO)

Street Address

Apartment #

City

State

Zip Code

6

Vehicle Information (PERSONAL AUTO)* This field is required. INCLUDE: YEAR, MAKE, VIN (OPTIONAL), FULL COVERAGE, and COMPREHENSIVE AND COLLISION DESIRED DEDUCTIBLES.

7

Current Coverage Information (PERSONAL AUTO)

Name of current Insurance provider?

# of years with current insurance provider?

Expiration date on your policy?

What is your current premium?

8

Current Liability Coverage (PERSONAL AUTO)* This field is required.

25,000/65,000

50,000/100,000

100,000/300,000

250,000/500,000

None/Other

9

Desired Liability Coverage (PERSONAL AUTO)* This field is required.

25,000/65,000

50,000/100,000

100,000/300,000

250,000/500,000

Other

10

Driver Information? (PERSONAL AUTO)Please include the following for each driver: Full Name | Sex | DOB | Marital Status Driver's License # & Issued State

11

Accidents & Violations? (PERSONAL AUTO)Please Include the Following Driver | Date | and Type of Incident (if any)

12

Other Information? (PERSONAL AUTO)Additional Information or Concerns/Needs

13

Contact Information (RV)* This field is required.How can we contact you?

First Name

Last Name

Please enter your email

Please enter your phone

14

Your Address? (RV)

Street Address

Apartment #

City

State

Zip Code

15

Vehicle Information (RV)* This field is required. INCLUDE: YEAR, MAKE, VIN (OPTIONAL), FULL COVERAGE, and COMPREHENSIVE AND COLLISION DESIRED DEDUCTIBLES.

16

Current Coverage Information (RV)

Name of current Insurance provider?

# of years with current insurance provider?

Expiration date on your policy?

What is your current premium?

17

Current Liability Coverage (RV)If you have current coverage, what is your Liability coverage amount?

18

Desired Liability Coverage (RV)What is your desired liability coverage amount?

19

Driver Information? (RV)Please include the following for each driver: Full Name | Sex | DOB | Marital Status Driver's License # & Issued State

20

Accidents & Violations? (RV)Please Include the Following Driver | Date | and Type of Incident (if any)

21

Other Information? (RV)Additional Information or Concerns/Needs

22

Contact Information (EARTHQUAKE & FLOOD)* This field is required.How can we contact you?

First Name

Last Name

Please enter your email

Please enter your phone

23

Your Address? (EARTHQUAKE & FLOOD)

Street Address

Apartment #

City

State

Zip Code

24

What are your needs for earthquake & flood insurance? (EARTHQUAKE & FLOOD)* This field is required.

25

Contact Information (Life Insurance)* This field is required.How can we contact you?

First Name

Last Name

Please enter your email

Please enter your phone

26

Personal Information (Life Insurance)* This field is required.

Date Of Birth

Age

Sex

27

What are you looking for? (Life Insurance)* This field is required.

Beneficiary name

Secondary Beneficiary name

Spouse Coverage Desired?

Type Of Insurance Desired?

Death Benefit Amount Desired (usually 8-10 years of income is best)

28

Health Questions (Life Insurance)* This field is required.

Any medications taken?

Any health concerns?

Have you been diagnosed with any condition by a member of the medical field in the last 10 years?

29

If you answered yes to any of health questions above, for privacy & security reasons we won’t gather the details of any of that info online, but one of our representatives can reach out to you go over that info and how it may/may not impact rates, or eligibility.

We partner with over 100 carriers to provide you the best coverage, and the best possible price.

30

Would you like us to send you a calendar link to pick your own time in our schedule?* This field is required.

YESNO

31

Business Information (Commercial AUTO)* This field is required.

Business Name

DBA (if applicable)

Please enter your email

Please enter your phone

32

Your Address? (CommAuto)

Street Address

Apartment #

City

State

Zip Code

33

Vehicle Information (CommAuto)* This field is required. INCLUDE: YEAR, MAKE, VIN (OPTIONAL), FULL COVERAGE, and COMPREHENSIVE AND COLLISION DESIRED DEDUCTIBLES.

34

Current Coverage Information (CommAuto)

Name of current Insurance provider?

# of years with current insurance provider?

Expiration date on your policy?

What is your current premium?

35

Current Liability Coverage (CommAuto)If you have current coverage, what is your Liability coverage amount?

36

Desired Liability Coverage (CommAuto)What is your desired liability coverage amount?

37

Driver Information? (CommAuto)Please include the following for each driver: Full Name | Sex | DOB | Marital Status Driver's License # & Issued State

38

Accidents & Violations? (CommAuto)Please Include the Following Driver | Date | and Type of Incident (if any)

39

Other Information? (CommAuto)Additional Information or Concerns/Needs

40

Business Information (BUSINESS LIABILITY)* This field is required.

Business Name

What kind of work does your business do?

Business Owner's First Name

Business Owner's Last Name

Business Owner's Date Of Birth

Business Owner's Age

41

Business Address (BUSINESS LIABILITY)

Street Address

Apartment #

City

State

Zip Code

42

More Information (BUSINESS LIABILITY)* This field is required.

Business Ownership Type

Number of years you've been in this business

43

How can we contact you? (BUSINESS LIABILITY)* This field is required.

Phone Number

Email

44

Contact Information (Business Personal Coverage)* This field is required.How can we contact you?

First Name

Last Name

Please enter your email

Please enter your phone

45

Your Address? (Business Personal Coverage)

Street Address

Apartment #

City

State

Zip Code

46

What are your needs for Business Personal Coverage insurance?* This field is required.

47

Personal & Family Coverage (Other) Please let us know more about your needs

48

Business Information (WORKERS COMP)* This field is required.

Business Name

DBA (if applicable)

Please enter your email

Please enter your phone

49

What are you looking for? (WORKERS COMP)* This field is required.

50

Contact Information (UMBRELLA)* This field is required.How can we contact you?

First Name

Last Name

Please enter your email

Please enter your phone

51

Your Address? (UMBRELLA)

Street Address

Apartment #

City

State

Zip Code

52

What are your needs for umbrella insurance? (UMBRELLA)* This field is required.

53

Contact Information (HOME)* This field is required.How can we contact you?

Property Owner 1 First Name

Property Owner 1 Last Name

Please enter your email

Please enter your phone

Spouse or Property Owner 2 First Name

Spouse or Property Owner 2 Last Name

Add Note Here, if needed

54

Your Address? (HOME)

Street Address

Apartment #

City

State

Zip Code

55

Occupancy Type? (HOME)* This field is required.

Home Primary Residence

Rental Property (Tenant Occupied)

Tenant (You are Renting the Property

Secondary Residence

Condo/Primary Residence

Other

56

Property Owner DOB(s)? (HOME)

Property Owner 1 Date of Birth

Property Owner 2 or Spouse Date of Birth

57

Current Homeowner's Insurance Info? (HOME)* This field is required.Please include the following information: Name of Current Homeowners Insurance Provider Expiration Date of Policy Dwelling-Property Insurance Amount Deductible Annual Premium

58

Contact Information (OTHER)* This field is required.How can we contact you?

First Name

Last Name

Please enter your email

Please enter your phone

59

Your Address? (OTHER)

Street Address

Apartment #

City

State

Zip Code

60

What are your needs? (OTHER)* This field is required.

61

Prepopulated