Insurance Quote Form
Please help me quote you more efficiently by providing the information on this and the subsequent pages, if applicable.
Where did you learn about my services? This helps me know how to best advertise:)
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Please Select
I was referred to Evan
Social Media/Internet
Merchandise/Flyer
Evan reached out to me
Name
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First Name
Last Name
Email
*
example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Address (Please provide address of new home if you are moving)
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you interested in an auto policy quote? If yes, please fill out the Auto-Specific and Current Policy tabs.
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Yes
No
Are you interested in a home policy quote? If yes, please fill out the Home-Specific and Current Policy tabs.
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Yes
No
Are you interested in a commercial policy quote? If yes, please fill out the Commercial-Specific and Current Policy tabs.
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Yes
No
Are you interested in quotes for any of the following policies?
Landlord
Renter's
Flood
Life
Other
Best day(s)/time(s) to contact you?
Preferred method of contact?
Text
Email
Call
Any of the above
When do you need a new policy by?
Please provide a brief description of your occupation and education level to take advantage of any available discounts.
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Auto Policy Required Information
Please fill out the following for an auto policy quote.
Driver's License Number
VIN number(s), primary driver name, and rough estimate of commutes for each vehicle to be insured.
Name(s), driver's license number(s), and DOB(s) for additional driver(s)
Desired amount of liability coverage and/or deductible amounts:
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Home Policy Required Information
Please fill out the following for a home policy quote.
For Home Insurance, please list any updates to the house and year of updates (roof, plumbing, HVAC, electric, etc.) and any security devices in the home (detectors, alarms, etc.)
Please list any personal property items that are of high value to make sure I have them adequately covered.
Desired deductible amount:
Please list any dogs owned and their breeds.
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Commercial Policy Required Information
Please fill out the following for a commercial policy quote
Name of Business
Please explain the nature of your business in detail including a link to your website if you have one.
Estimated Gross Income
Entity Type
CORPORATION
INDIVIDUAL
JOINT VENTURE
LLC
Other
FEIN
Address of all business premises
Please list types of business coverage you need and how much coverage you would like.
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Current Policy
If you are already insured, please list current insurer and upload current policies/declaration pages or email them to me at evan@legacyinsurance1.com
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