PRE-FILLED WEB

PREFILLED QUOTE REQUEST

Enter your personal information below
Agent Version

You are now in agent mode.
1. Agent email*
Select agent first.
0. Send to Customer*

YESNO
With this form, we'll collect your personal information and associate it with a Customer Information Number (CIN).

We will use this CIN number on quote requests, meaning We will PRE-FILL all your information; you won't have to re-enter your personal information on future quote requests.

Your CIN is {2Cin}
Welcome to PRL Insurance's PREFILLED Quote request forms.

Nothing is more aggravating than filling out a long form adding addresses, personal information, phone numbers, etc. Then you have to turn around and do it over again the next time you want a different quote.

We value your time. That's why we have created PREFILLED Quote request forms. Fill out the following form, and a “Customer Information Number” (CIN) will be assigned to your personal information.

Your CIN includes all the information you enter on this form. Things like SSN, addresses, previous addresses, phone numbers, co-applicant information, etc.

YOUR CIN IS: {2Cin}

After submitting this form, select which type of insurance quote you want. Your CIN* will be transferred/ linked to the selected prefilled quote request form. Give it a try, and it's never been easier to fill out multiple prefilled quote request forms quickly.

*Military-grade 128-bit encryption protects your personal information.
PRIMARY APPLICANT

It's all about you!
2. Customer Information Number (CIN)
3. Email*

Confirmation EmailEnter the customer’s email
4. Name

First Name Middle Initial Last Name
5. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
6. Same as mailing address

YESNO
7. Mailing address

Street Address

Street Address Line 2

City) State / Province

Postal / Zip Code
8. Same residence for the last 3 years

YESNO
9. Previous address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
10. Cell
11. Home
12. Work
13. Date of birth
14. SSN
Your information is secure.
15. Gender

FemaleMale
16. Education
17. Marital status
18. Employment
19. Occupation
19.1. Will there be a co-applicant?

YESNO
CO-APPLICANT

It's all about them!
20. Name

First NameMiddle InitialLast Name
21. Address same as Primary applicants?

YESNO
22. Address (other)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
23. Date of birth
24. SSN
Your information is secure.
25. Gender

FemaleMale
26. Education
27. Marital status
28. Employment
29. Occupation
By submitting this form, you acknowledge PRL Insurance could and may access consumer report information such as claims histories and credit-based insurance scores where permitted by law to determine the premium you pay for insurance coverage.

Your insurance score uses information from your credit report to help predict how often you're likely to file a claim, and how expensive those claims will be. When we access your credit-based insurance score, it has no impact on your credit rating.

Both your Social Security Number and insurance score are kept confidential and secure, and will not be resold or redistributed. We may also submit your information to an authorized third party to obtain and prefill information about your property for you to confirm when you complete the quote request application.
Customer initials
Please enter your initials so we know you're a real person.
Should be Empty:

PREFILLED QUOTE REQUEST

Agent Version

PRIMARY APPLICANT

CO-APPLICANT