Home & Auto Insurance Quote
Complete the required fields and a representative will contact you. However, the more fields you fill out, the more accurate your quote will be.
Primary Insured - Full Legal Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth
*
-
Month
-
Day
Year
Date
Do you own or rent the house you live in?
*
Rent
Own
Highest level of education
*
High School/GED
Associates Degree
Bachelors Degree
Masters Degree
Other
Drivers License State and Drivers License Number
*
########FL
Gender
*
Male
Female
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Do you work for the school system?
Please Select
Yes
No
Occupation
Marital Status
Single
Married
Widowed
Divorced
Separated
Registered Partnership
Other
Are you a Triple A member?
Please Select
Yes
No
How did you hear about us? *select all that apply*
Search Engine
Facebook
Instagram
LinkedIn
Word of Mouth/Referral
School Event and/or Workshop
Mailer or Print Advertisement
Other
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Primary Insured Vehicle
Upload Current Auto Insurance Dec Form
Browse Files
Drag and drop files here
Choose a file
*Optional
Cancel
of
Primary Insured Vehicle
When does your current policy renew?
-
Month
-
Day
Year
Date
Current auto insurance company provider?
Are there additional individuals to insure?
Please Select
Yes
No
Are there additional vehicles to insure?
Please Select
Yes
No
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Additional Vehicle
Insured Vehicle
Are there additional vehicles to insure?
Please Select
Yes
No
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Insured Vehicle
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Secondary Insured Individual
Secondary Insured - Full Legal Name
First Name
Last Name
Secondary Date of Birth
-
Month
-
Day
Year
Date
Drivers License State and Drivers License Number
########FL
Occupation
Highest level of education
High School/GED
Associates Degree
Bachelors Degree
Masters Degree
Other
Are there additional individuals to insure?
Please Select
Yes
No
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Additional Insured
Additional Insured - Full Legal Name
First Name
Last Name
Additional Insured Date of Birth
-
Month
-
Day
Year
Date
Drivers License State and Drivers License Number
FL #######
Occupation
Highest level of education
High School/GED
Associates Degree
Bachelors Degree
Masters Degree
Other
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Homeowners Questions
Upload Current Homeowners Dec Form
Browse Files
Drag and drop files here
Choose a file
*Optional
Cancel
of
Current dwelling coverage amount or sale price if it is a new purchase?
Do you have a fence, shed, or both?
Fence
Shed
Both
None
Do you have a monitored alarm system - for fire, burglar, or both?
Only fire
Only burglar
Both
None
How old is your roof? (In years)
Has your roof been replaced? If yes, what year?
Have you had a wind mitigation inspection performed on your home?
Yes
No
Has this property experienced any sinkhole or settlement issues?
Yes
No
Is your home located in a gated community?
Yes
No
Do you have any dogs? If yes, what breed?
Do you have a trampoline?
Yes
No
Who is your current homeowners insurance policy with?
Current deductibles and premium
Have you filed any claims in the past 5 years regardless of a pay out?
Yes
No
If yes, did it involve an AOB or lawsuit?
AOB
Lawsuit
Not applicable
Other
Have you filed for bankruptcy or foreclosure in the last 5 years?
Please Select
Yes, foreclosure
Yes, bankruptcy
No
Property Address to Insure
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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By submitting this form, I agree to be contacted via text, phone call, or email by Florida Educators Insurance and GAC Wealth Management regarding products and services. I understand that my coverage or policy cannot be changed or updated via this service form.
*
I agree.
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