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Personal Insurance Discovery Form
Form Instructions & Info
Download Fillable PDF Form Below (right click on the form to download and complete)
Need By Date:
-
Month
-
Day
Year
(Typically 5 day turnaround)
Requested By:
*
Your Name
Referred By:
*
If none - just put your name
What Type of Insurance Do You Need?
Just Home
Just Auto
Home & Auto (bundled savings)
Home, Auto & Umbrella (bundled savings)
General Information
Named Insured
*
First Name
Last Name
Email
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Primary Insured
Driver's License #
*
Primary Insured
DL State Issued
*
State on License
Employer
Marital Status
*
Single
Married
Divorced
Widowed
Separated
Additional Insureds
Primary Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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🏠 Property Rating Information 🏠
Current Home Insurance Carrier
Current Insurance Company
Years with Current Home Carrier
Approximate
Current Home Premium
Annual amount
Current Home Policy Expiration Date
-
Month
-
Day
Year
Date
Year Built
Square Footage
Approx. - not including basement
Number of Stories
Do not include basement
Roof Shape - See below for help
Gable
Hip
Gambrel
Flat
Shed
Complex
Other
Age of Roof
*
# of Years Old - Approx.
Roof Type
Asphalt Shingle (most common)
Metal
Solar
Other
Construction Type
Frame
Masonry
Solid Concrete
Other
Siding Type
Vinyl
Masonry / Veneer
Brick
EIFS
Wood
Other
Property Contain Any of These Items (Pool, Trampoline, Wood Stove)?
Pool
Trampoline
Wood Stove
None
Restricted Dog Breed on Property?
No
Yes - if so, click "other" below and put in breed name
Other
Foundation
Finished Basement
Partial Finished Basement
Unfinished Basement
Slab
Crawlspace
Date Home Purchased
Approximate
Update / Replacement Dates (if applicable)
Fire Hydrant or Fire Department Proximity
Approximate
Current Home Billing Plan:
Monthly
Quarterly
Annually
Mortgage Billed (most common)
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🏠 Property Endorsements 🏠
Match Your Current Home Coverages?
Please Select
Yes
No
Refer to Declaration Pages
** Must submit current declaration pages at the end if you want us to compare current coverages to new **
Amount of Desired Water Backup Coverage
$ Amount - None - or Agency Suggestion
Equipment/Mechanical Breakdown Coverage?
Yes - If Available
No
Replacement Cost for your Home
100%
125%
150%
Guaranteed Replacement - if applicable
Personal Injury Coverage?
Yes
No
Personal Property Coverage
$ Amount
Service Line Coverage?
Yes
No
Do you have another home to add?
Yes
No
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🚗 Auto Rating Information 🚗
Current Auto Carrier?
Insurance Carrier
Time with Current Carrier?
Approximate
Current Auto Insurance Premium
Annual
Current Auto Policy Expiration Date
-
Month
-
Day
Year
Date
Match Current Auto Coverages?
Please Select
Yes
No
Refer to Declaration Pages
Autos
Auto Billing Plan (CURRENT):
Monthly
Quarterly
6 Months
Annually
Auto Billing Plan (PREFERRED):
*
Monthly
Quarterly
6 Months
Annually
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🚗 Auto Endorsements 🚗
Auto Liability Amounts
$50k/$100k
$100k/$300k
$250k/$500k
$1,000,000
Added Coverage?
Full Glass
OEM Parts
Rental Car (minimum)
Roadside (minimum)
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☂️ Personal Umbrella ☂️
Umbrella Coverage
None
$1,000,000
$2,000,000
$3,000,000
UM/UIM
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Document Upload & Other Information
File Upload - Declaration Pages & Any Other Quotes
Browse Files
Drag and drop files here
Choose a file
To receive an Apple Report (side-by-side comparison), current Declaration pages must be submitted.
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Additional Info / Request / Notes:
You can Submit this form, after hitting Review below.
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