Home & Auto Quote
Please fill this form out to the best of your ability.
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Personal Information
How did you hear of Norgaard Agency?
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Full Name
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First Name
Last Name
Middle Initial
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Date of Birth
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Marital Status
Single
Married
E-mail
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Phone Number
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Area Code
Phone Number
Do you utilize texting?
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Yes, please send me an opt-in text
No, I prefer not to text
Address
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Separate mailing address?
Yes
No
Prior address if you have moved within the last two years
Employment Status
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Employed
Unemployed
Retired
Unable to work
Occupation
Current Employer & Length of Time at Current Employer
2nd Named Insured Information
This section is only required if there will be a spouse or partner named on your policy (not including minors under the age of 18)
Full Name
First Name
Last Name
Middle Initial
Date of Birth
Martial Status
Single
Married
Email
example@example.com
Phone Number
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Area Code
Phone Number
Employment Status
Employed
Unemployed
Retired
Unable to work
Occupation
Current Employer & Length of Time at Current Employer
Minor Information
This section is only required for minors, 18 years or younger in the household
Please list all minors 18 years or younger in the household. (Full Name and Age)
Are any of your policies being cancelled or non-renewed? If so, please explain:
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Home Information
This section is only applicable to those inquiring about a homeowners insurance quote
Address (If different than previously listed)
New Purchase
Yes
No
Primary Residence
Yes
No
Home Currently Insured
Yes
No
Current home insurance carrier and for how long
How do you typically pay?
Monthly
Pay in Full
Is there a loan on the home? If so, please list the mortgagee and their mailing address.
Mortgagee Information for each property:
Have you filed for bankruptcy or had a foreclosure? If so, please list what year.
Have you filed any home claims within the last five years? If so, please elaborate (year, loss type, amount paid)
What year was the home built
Please indicate the type of build
Please Select
Traditional Stick Build
Modular
Mobile home
Manufactured home
How many stories?
Foundation
Please Select
Crawlspace
Slab
Basement – unfinished
Basement – partially finished
Basement – fully finished
How is your home heated? Is there a back-up heat source?
Does the home have any wood or pellet heat?
Yes
No
Have the roof, heat, plumbing, or electrical been updated since the home was built? If so, please indicate what year?
Roof Type & Shape
Square Footage (Above Ground)
Please list all detached structures on the property along with the estimated measurements and if the building is heated:
Please indicated if your home has an attached garage and if so, how many stalls there are:
List property acreage and indicate if land is rented for farm use:
Please select all that apply
Local Fire Alarms
Local Smoke Detector
Security Systems/Cameras
Gated entry to property
Is the home within city limits
Yes
No
If known, please list the distance to the nearest fire department and fire hydrant
Please select all that apply
Fully fenced pool with locking gate
Above-ground pool
In-ground pool
Trampoline
Hot tub
Fenced yard
Are there any dogs or farm animals on the property? If so, please list the number and breed/type
Upload Homeowners Declaration Sheet (Lists current coverages)
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If you do not have your current dec. sheet, please provide us with your current/desired coverages
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Auto Information
This section is only applicable to those inquiring about an auto insurance quote
Please list the names and driver's license numbers for all drivers on the policy
Auto Currently Insured
Yes
No
Current auto insurance carrier and for how long
How do you typically pay
Monthly
Pay in Full
Vehicle 1
Year, Make, Model, 2DR/4DR, 2WD/4WD, VIN #, Use (pleasure or commute), and primary driver
Vehicle 2
Year, Make, Model, 2DR/4DR, 2WD/4WD, VIN #, Use (pleasure or commute), and primary driver
Vehicle 3
Year, Make, Model, 2DR/4DR, 2WD/4WD, VIN #, Use (pleasure or commute), and primary driver
Vehicle 4
Year, Make, Model, 2DR/4DR, 2WD/4WD, VIN #, Use (pleasure or commute), and primary driver
Any Recreational Vehicles?
Snowmobile, Motorcycle, ATV, Side by Side
Lienholder on each vehicle along with their mailing address:
Auto Coverages
Please skip the below questions if you are uploading an auto declaration page that details your current coverages
Limits
Please Select
25/50
50/100
100/300
250/500
Under/Uninsured Motorists
Roadside Assistance Desired?
Yes
No
Comprehensive Deductible
Please Select
$100
$250
$500
$1000
Collision Deductible
Please Select
$100
$250
$500
$1000
Violations / At-Fault Accidents / Claims Within Last Five Years
Who, when, what
Upload Current Auto Policy / Declaration Page
Browse Files
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When do you need this quote by/when does your current coverage expire?
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Month
-
Day
Year
Date
Form completed by:
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Please verify that you are human
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Thank you for thinking of Norgaard Agency!
We appreciate you taking the time to fill out this form. We will get to work on reviewing your submission and be in contact within 48 hours. If you should have immediate concerns, please feel free to call us at 715-284-5115.
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