Account Quote Sheet
Quote. Sell. Repeat
Your Name
First Name
Last Name
Your Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
How were they referred to Wenatchee Insurance agency?
*
What Lines of Business are we quoting
Car
Home
Bussiness
Health
Life
Other
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Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
Date
Social Security/ Tax Identification number
Occupation
Drivers License Number
Marital Status
Please Select
Married
Single
Divorce
Widowed
What is spouse's name?
First Name
Last Name
Spouses driver's license
Spouse's date of birth
 -
Month
 -
Day
Year
Date
Spouse's Social Security/ Tax Identification number
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Automobile Quote
How many Additional Household members?
Please Select
none
1
2
3
4
Additional Licensed Driver
First Name
Last Name
Additional Licensed Driver Date of Birth
 -
Month
 -
Day
Year
Date
Driver's Licence #
Additional Licensed Driver Name
First Name
Last Name
Additional Licensed Driver Date of Birth
 -
Month
 -
Day
Year
Date
Driver's License #
Additional Licensed Driver Name
First Name
Last Name
Driver's License
Additional Licensed Driver Date of Birth
 -
Month
 -
Day
Year
Date
How many cars total in household
Please Select
1 car
2 cars
3 cars
4 cars
5 cars
Car 1
Year
Make
Model
Vin
Odometer
Car 2
Year
Make
Model
Vin
Odometer
Car 3
Year
Make
Model
Vin
Odometer
Car 4
Year
Make
Model
Vin
Odometer
Car 5
Year
Make
Model
Vin
Odometer
Do you drive your vehicle for work?
Please Select
Yes
No
How far to your workplace?
Coverages
Current Insurance Company
Policy Expiration Date
 -
Month
 -
Day
Year
Date
How long with current company?
Policy term
6 month
12 month
Current Liability Limits
Person
People
Property
Additional information
Need an SR-22
Have a Lease or Loan on vehicle
Interested in PIP
Interested in Towing
Interested in Glass Replacement
Interested in Umbrella Coverage
Broadform
Any accidents or tickets in the last 3 years? If none then state none.
*
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Homeowners /Renters
Property Type
Please Select
Single Family
Manufactured
Duplex
Condo
Townhouse
Renters
Location Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Prior Address (if applicable)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Year Built
Exterior Construction
Please Select
Masonry Veneer
Frame
Log
Wood
Masonry
Mobile Home
Square Footage
Foundation Type
Please Select
Slab
Crawlspace
Basement
Stilts
Other
Roof Type
Please Select
Shingle
Metal
Tile
Rubber/Flat
Other
Roof Age in years
*
How was the age of the roof verified?
Please Select
Customer
Realtor
Inspection
Listing
Applicable Discounts
Central Burglar Alarm
Central Fire Alarm
Leak / Water Detection Sensors
Liability Exposures
*
Dog (s)
Livestock
Trampoline
Pool
More than 5 Acres
None Apply
Dwelling Condition
Please Select
Poor
Average
Fair
Excellent
Would the Insured like protection from flood
*
Please Select
Customer Declined
Yes
Would the Insured like protection from Earth Movement
*
Please Select
Customer Declined
Yes, sinkhole
Yes, Earthquake
Sinkhole & Earthquake
Will underwriting be requiring a picture of the home?
*
Please Select
Yes
No
Notes about home
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Business
Name of business
What does your business do?
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Contact Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
The building is
free standing.
connected.
Do you lease or own the building that your business operates from?
Own
Lease
Other
What is the square footage of the building?
Does your building have a fire suppression system?
What is the minimum liability coverage listed on your lease or mortgage requirements?
Business Website
Is it a shared space?
Yes
No
Does your building have a security or alarm service?
Yes
no
What is the square footage?
total square footage
square footage used by business
Annual Revenue
Concerning alcohol, my business sells
Please Select
no alcohol
a beer and wine license
liquor license
What percentage of sales is food to alcohol
Does your business have the following?
An Oven
Fryer
Open Flame
Bar
Walk-in Fridge/Freezer
The replacement cost for all equipment owned and used by your business?
less than $25,000
$25,000 to $50,000
$50,000 to $100,000
more than $100,000
other.
Does your equipment include drones or aviation equipment?
Yes
No
How many employees/interns does your business employ?
Do you or your employees travel for work? for example delivery.
Yes
No
Other
Does your business use liability waivers? If so what for?
Does your business need
Additional certificates of insurance for leased equipment/landlord
waiver of subrogation?
Bonds
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Life
You checked the life box. We do most of the applications in person because there is a lot of misunderstanding and bias to these products. Some people love term. Some people prefer the tools that a permanent policy that provides. We believe that our customers should have access to an licence agent to assist in this important decision.
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Health
Medicare, Apple Health, Qualified Health Plan, Travel, Dental, and/or vision
I need to talk about Medicare
Please Select
Not at this time
I am needing to enroll.
I need help because something has changed.
I need to talk about Apple Health
Please Select
I used to qualify.
My needs have changed.
I need to get my kids covered.
I need help understanding it.
Qualified Healthplan
Please Select
I am covered.
I need help with an application.
I need help understanding what I have.
I am looking for additional coverages
Accident Plan
Travel Plan
Dental Coverage
Vision Coverage
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Notes
This document will become a permanent record in this clients file. Underwriting and coverage decisions by our sales, service team, and carriers will rely on this information to be accurate. By initialling below, you acknowledge that all the information included with this document is accurate and was provided to you by the client.
Initials
additional notes
Submit
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