Insurance Quoting Form

1

Which Insurance Product Did You Want A Quote For?* This field is required.

2

Were You Referred By Someone? If Yes, List Who?* This field is required.If no one referred you please just put "none"

3

Customer Name* This field is required.

First Name

Last Name

4

Birth Date* This field is required.

5

License Or State ID Number* This field is required.

6

What State Was Your License Or State ID Issued?* This field is required.

7

Please Select Your Gender* This field is required.

Male

Female

8

E-mail* This field is required.

example@example.com

9

Phone Number* This field is required.

10

Current Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

11

Do you own the home you live in or do you rent?

I Rent

I Own My Home

I Live With Family

12

What Level Of Education Do You Have?* This field is required.

13

Describe Your Job Occupation* This field is required.If you are currently not employed list "unemployed" and if you are a full time student please list "student" and if you are currently working please list a description on what you do.

14

Do You Need To Add Another Driver?* This field is required.

YESNO

15

Secondary Driver Name?

First Name

Last Name

16

Secondary Date Of Birth?

17

Secondary License Number And State?

18

Vehicle 1

19

Primary Vehicle Use* This field is required.

20

Vehicle Purchase Date

21

Odometer ReadingPlease provide us the current mileage on your vehicle.

22

Vehicle Purchase Price

23

Type a Are You Currently Financing This Vehicle? If Yes, Please List Lienholder Below. If There Is No Loan Please Put "None"* This field is required.

24

Please select any additional coverages you would like to have.

Comprehensive

Collision

Uninsured Motorist

Rental Reimbursement

Roadside/Towing

Covered

Comprehensive

Collision

Uninsured Motorist

Rental Reimbursement

Roadside/Towing

25

What deductibles would you like for comprehensive and collision coverage?Please be aware that if you have a loan on the vehicle you MUST HAVE Deductibles selected.

Liability Only

$250

$500

$1000

26

What deductible would you like for your homeowners insurance?Please be aware that your mortgage company may require you to have a deductible lower than you may desire. Make sure to confirm prior to purchasing policy as price can change.

$1000

$2000

$2500

$5000

1%

2%

5%

27

IF you have more then 1 vehicle then please list vin numbers them here

28

What kind of life insurance were you looking for?

Term

Index Universal Life (IUL's)

Whole Life

Fixed Indexed Annuities

Not Sure

30

Do you currently take medications? Please list them below (if applicable).

34

Would you like water backup of sewers and drains?This is NOT flood insurance.

YESNO

35

Do you have a home-based business you operate out of your home?

YESNO

36

Have You Made Updates To Any Of The Following?Please provide the year it was updated.

Electrical

Plumbing

Heating & Cooling

Roofing

37

Any other information you would like to provide?

38

Upload Photo of Drivers License(s) or ID's

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

39

Upload Photo of Vin Number(s)

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

40

Upload Photo of Prior Insurance Declarations PageApplicable only if you had prior insurance within past 6 months without any lapses in coverage.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

41

Would You Like To Be Set Up On Autopay?* This field is required.This means that your insurance company will automatically debit your account/card every month to cover your insurance payment.

YESNO

42

IMPORTANT DISCLOSURE

Pursuant to the authority set forth in Section 27-12-17, Code of Alabama 1975, insurance producers may collect administrative fees not in excess of the following schedule when processing applications for property and casualty insurance:

Any of the following:

- New Application: $30.00

Plus any and all of the following as applicable:

- Photo of Auto: $5.00

- Motor Vehicle Reports: Actual Cost

- Cash Payments Received In Agency: $5.00

- Credit Card processing charge for accepting payment: Actual cost, not to exceed 3.25%

These administrative fees are separate and distinct from the insurance company's premium.

43

By signing below you are agreeing and understanding that your quote may contain fees which includes the following: (1) Application Fees, (2) Motor Vehicle Report Fees [Per Driver], (3) Photos Of Vehicle Surcharge, (4) Cash Payments Received In Agency, and (5) Merchant Processing Fees. By Signing below you are agreeing to these charges and withhold any legal action at time of sale and onward. (Fees only charged at time of policy sale and only on quotes for illustration purposes).* This field is required.

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