Intra-Agency Personal Lines Quote Questionnaire
This form is specifically for Williamson Insurance & Investments employees. If you are not an employee, please redirect to https://agentwilliamson.com/quote for a more streamlined experience.
Team Member Completing Questionnaire
Wes Williamson
Blair Williamson
Blake Shelby
Stephen Sanders
Miracle Easterling
Brett Richmond
Other: Type Name
Assign this Lead to (BoB):
Wes Williamson
Blair Williamson
Blake Shelby
Stephen Sanders
Miracle Easterling
Brett Richmond
Quoting Team Williamson
Not Sure
Other
Prospect Name
*
First Name
Last Name
How did you hear about us?
How did you hear about us?
Please Select
A Referral Partner
A Satisfied Client
Networking
Producer Family
Producer Friend
Call-in
Walk-in
Website
Rewrite
Cross-Sale
Cold/Old PL Leads
Our Event
Facebook
Instagram
LinkedIn
Twitter
Yelp
Winback
Other
Preferred Contact Method
Please Select
Call
Text
Email
In Person
Video Meeting (Microsoft Teams)
Video Meeting (Zoom)
Other
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Time at Address
Future Address
Less than 2 Years
More than 2 Years
Prior Address
Street Address Line 1
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
/
Month
/
Day
Year
Marital Status
Please Select
Single
Married
Separated
Divorced
Widowed
Residence Occupancy
Own
Rent
Other
Lines to Quote Now
Auto
Homeowners
Renters
Condo
Manuf. Home
Landlord (Long Term Rental)
Landlord (Short Term Rental)
Secondary Home
Vacant Home
Motor Home
Travel Trailer
Trailer
Motorcycle
ATV/Off Road
Boat
Valuable Items
Umbrella
Life
Membership
Other
Lines to Possibly Quote Later
Auto
Homeowners
Renters
Condo
Manuf. Home
Landlord (Long Term Rental)
Landlord (Short Term Rental)
Secondary Home
Vacant Home
Motor Home
Travel Trailer
Trailer
Motorcycle
ATV/Off Road
Boat
Valuable Items
Umbrella
Life
Membership
Other
Carriers to Quote Outside of Rater
AAA
Allstate
American Modern
Hagerty
PersonalUmbrella.com
REInsure
Steadily
Other
May team contact for additional info?
Yes
No
Check with Agent first
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Auto
Please note: None of the information on this page is required. However, the more information you provide helps us find the most accurate coverage options and rates for you.
Desired Effective Date
/
Month
/
Day
Year
Would you like to upload documents? Your current Declarations Pages (Policy Documents) can provide information such as VINs and other information about your current situation.
Yes
No
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Current/Previous Carrier
Please Select
I'm not sure
21st Century Insurance
AAA
AARP
Acceptance
Acuity
Alfa
Allstate
American Family
American Modern
Amica
Arrowhead
Auto-Owners
Bristol West
Chubb
Cincinnati
Clearcover
Country Financial
Countrywide
Dairyland
Direct Auto
Elephant
Encompass
Erie
Farm Bureau
Farmers
Foremost
GAINSCO
Geico
Grange
Hanover
Hartford
Infinity
Kemper
Lemonade
Liberty Mutual
Mercury
National General
Nationwide
Progressive
PURE
Root
SafeAuto
Safeco
Safety
Secura
Shelter
State Auto
State Farm
Stillwater
Tesla
The General
Travelers
USAA
Westfield
No Previous Insurance
Other
Current Monthly Premium (if known)
Driver Information
Vehicle Information (Skip if uploading Policy Documents)
Would you like to enter lienholder info at this time?
Yes
No
Lienholder Info
Coverage Options
I would like to select my options
Please match my current policy
I need guidance on coverage options
Bodily Injury Liabilty
Please Select
25/50
50/100
100/300
250/500
500/500
100 CSL
Property Damage Liability
Please Select
25
50
100
250
500
Incl. in CSL
Uninsured Motorist Bodily Injury
Please Select
25/50
50/100
100/300
250/500
500/500
50 CSL
100 CSL
300 CSL
500 CSL
Uninsured Motorist Property Damage
Please Select
25
50
100
250
500
Incl. in CSL
Medical Payments
Please Select
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$10,000
Other
Custom Equipment
Further Information
Smartphone App to track safe driving habits (Discount)
I drive for Uber/Lyft/etc.
One or more drivers requires SR22 Filing
Other
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Homeowners (HO3/HO5)
Please note: None of the information on this page is required. However, the more information you provide helps us find the most accurate coverage options and rates for you.
Desired Effective Date
/
Month
/
Day
Year
Date
Would you like to upload documents? Your current Declarations Pages (Policy Documents) can provide information such as discount qualifications and other information about your current situation.
Yes
No
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Current/Previous Carrier
Please Select
21st Century Insurance
AAA
AARP
Acceptance
Acuity
Alfa
Allstate
American Family
American Modern
Amica
Arrowhead
Auto-Owners
Bristol West
Chubb
Cincinnati
Clearcover
Country Financial
Countrywide
Dairyland
Direct Auto
Elephant
Encompass
Erie
Farm Bureau
Farmers
Foremost
GAINSCO
Geico
Grange
Hanover
Hartford
Infinity
Kemper
Lemonade
Liberty Mutual
Mercury
National General
Nationwide
Progressive
PURE
Root
SafeAuto
Safeco
Safety
Secura
Shelter
State Auto
State Farm
Stillwater
Tesla
The General
Travelers
USAA
Westfield
None
Other
Current Annual Premium (if known)
Named Insured DL #
Named Insured SSN
Add a Second Named Insured? (Spouse, Co-Owner, etc)
Yes
No
Second Named Insured
First Name
Last Name
Second Named Insured DOB
/
Month
/
Day
Year
Date
Would you like to add Mortgagee Info at this time?
Yes
No
Mortgage Info
Would you like to provide detailed information about your home? (Square footage, # of Bathrooms, etc.) Unless this is a new-build, we can likely pull information from reports.
Yes
No
Please have agent contact me if home information is not automatically pulled from reports
Home Information
Further Information
Select All Applicable Exposures
Duplex/Triplex/Row Home
Trampoline (netted)
Trampoline (no net)
Swimming Pool (gated)
Swimming Pool (no gate)
Diving Board/Slide
Hot Tub/Spa
Secure Community
Historical Registry
Airbnb/VRBO/etc.
Hobby Farm
Secondary Heat
Local Fire Alarm
Central Fire Alarm
Local Burglar Alarm
Central Burglar Alarm
Fuse Box
Other
Coverage Options
I would like to select my options
Please match my current policy
I need guidance on coverage options
Coverage Information
Additional Coverage Options
Water Backup
Earthquake
Business in Residence
Ordinance or Law
Identity Recovery
Sinkhole
Other
Further Details (if needed)
Back
Next
Save for Later
Renters (HO4)
Please note: None of the information on this page is required. However, the more information you provide helps us find the most accurate coverage options and rates for you.
Desired Effective Date
/
Month
/
Day
Year
Date
Would you like to upload documents? Your current Declarations Pages (Policy Documents) can provide information such as discount qualifications and other information about your current situation.
Yes
No
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Current/Previous Carrier
Please Select
21st Century Insurance
AAA
AARP
Acceptance
Acuity
Alfa
Allstate
American Family
American Modern
Amica
Arrowhead
Auto-Owners
Bristol West
Chubb
Cincinnati
Clearcover
Country Financial
Countrywide
Dairyland
Direct Auto
Elephant
Encompass
Erie
Farm Bureau
Farmers
Foremost
GAINSCO
Geico
Grange
Hanover
Hartford
Infinity
Kemper
Lemonade
Liberty Mutual
Mercury
National General
Nationwide
Progressive
PURE
Root
SafeAuto
Safeco
Safety
Secura
Shelter
State Auto
State Farm
Stillwater
Tesla
The General
Travelers
USAA
Westfield
None
Other
Current Annual Premium
Named Insured DL #
Named Insured SSN
Add a Second Named Insured? (Spouse, Co-Owner, etc)
Yes
No
Second Named Insured
First Name
Last Name
Second Named Insured DOB
/
Month
/
Day
Year
Date
Would you like to provide detailed information about your home? (Square footage, # of Bathrooms, etc.) Unless this is a new-build, we can likely pull information from reports.
Yes
No
Please have agent contact me if home information is not automatically pulled from reports
Home Information
Select All Applicable Exposures
Trampoline (netted)
Trampoline (no net)
Swimming Pool (gated)
Swimming Pool (no gate)
Diving Board/Slide
Hot Tub/Spa
Secure Community
Sprinkler
Secondary Heat
Local Fire Alarm
Central Fire Alarm
Local Burglar Alarm
Central Fire Alarm
Fuse Box
Other
Coverage Options
I would like to select my options
Please match my current policy
I need guidance on coverage options
Coverage Information
Additional Coverage Options
Water Backup
Earthquake
Business in Residence
Ordinance or Law
Identity Recovery
Sinkhole
Other
Further Details (if needed)
Back
Next
Save for Later
Condo Owners (HO6)
Please note: None of the information on this page is required. However, the more information you provide helps us find the most accurate coverage options and rates for you.
Desired Effective Date
/
Month
/
Day
Year
Would you like to upload documents? Your current Declarations Pages (Policy Documents) can provide information such as discount qualifications and other information about your current situation.
Yes
No
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Current/Previous Carrier
Please Select
21st Century Insurance
AAA
AARP
Acceptance
Acuity
Alfa
Allstate
American Family
American Modern
Amica
Arrowhead
Auto-Owners
Bristol West
Chubb
Cincinnati
Clearcover
Country Financial
Countrywide
Dairyland
Direct Auto
Elephant
Encompass
Erie
Farm Bureau
Farmers
Foremost
GAINSCO
Geico
Grange
Hanover
Hartford
Infinity
Kemper
Lemonade
Liberty Mutual
Mercury
National General
Nationwide
Progressive
PURE
Root
SafeAuto
Safeco
Safety
Secura
Shelter
State Auto
State Farm
Stillwater
Tesla
The General
Travelers
USAA
Westfield
None
Other
Current Annual Premium
Named Insured DL #
Named Insured SSN
Add a Second Named Insured? (Spouse, Co-Owner, etc)
Yes
No
Second Named Insured
First Name
Last Name
Second Named Insured DOB
/
Month
/
Day
Year
Date
Would you like to provide detailed information about your home? (Square footage, # of Bathrooms, etc.) Unless this is a new-build, we can likely pull information from reports.
Yes
No
Please have agent contact me if home information is not automatically pulled from reports
Home Information
Coverage Options
I would like to select my options
Please match my current policy
I need guidance on coverage options
Coverage Information
Additional Coverage Options
Water Backup
Earthquake
Business in Residence
Ordinance or Law
Identity Recovery
Sinkhole
Other
Select All Applicable Exposures
Secure Community
Airbnb/VRBO/etc.
Secondary Heat
Local Fire Alarm
Central Fire Alarm
Local Burglar Alarm
Central Fire Alarm
Fuse Box
Other
Further Details (if needed)
Back
Next
Save for Later
Valuable Items
Please note: None of the information on this page is required. However, the more information you provide helps us find the most accurate coverage options and rates for you.
Desired Effective Date
/
Month
/
Day
Year
Date
Would you like to upload documents? Your current Declarations Pages (Policy Documents) can provide information such as discount qualifications and other information about your current situation.
Yes
No
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Schedule of Items
Further Details (if needed)
Back
Next
Save for Later
Umbrella
Liability Limit Desired
Please Select
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
Over $5,000,000
Uninsured Motorist Umbrella Limit Desired
Please Select
No Additional Coverage
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
Over $5,000,000
Please list any exposures for which we do not have information, such as Landlord homes covered elsewhere.
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Landlord Home
Please note: None of the information on this page is required. However, the more information you provide helps us find the most accurate coverage options and rates for you.
Desired Effective Date
/
Month
/
Day
Year
Date
Would you like to upload documents? Your current Declarations Pages (Policy Documents) can provide information such as discount qualifications and other information about your current situation.
Yes
No
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Current/Previous Carrier
Please Select
21st Century Insurance
AAA
AARP
Acceptance
Acuity
Alfa
Allstate
American Family
American Modern
Amica
Arrowhead
Auto-Owners
Bristol West
Chubb
Cincinnati
Clearcover
Country Financial
Countrywide
Dairyland
Direct Auto
Elephant
Encompass
Erie
Farm Bureau
Farmers
Foremost
GAINSCO
Geico
Grange
Hanover
Hartford
Infinity
Kemper
Lemonade
Liberty Mutual
Mercury
National General
Nationwide
Progressive
PURE
Root
SafeAuto
Safeco
Safety
Secura
Shelter
State Auto
State Farm
Stillwater
Tesla
The General
Travelers
USAA
Westfield
None
Other
Current Annual Premium (if known)
Named Insured DL #
Named Insured SSN
Business Name (if applicable)
Second Named Insured DOB
/
Month
/
Day
Year
Date
Number of Homes
Please Select
1
2
3
4
5
6
7
8
9
10
>10
Schedule of Locations
Address
Dwelling Type
# of Units
Sqft
Desired Coverage A
Rental Income
Contents
Occupancy
Location 1
Single-Family Detatched
Single Family Attached
Multi-Unit
Condo
Manufactured Home
Other
1
2
3
4
5
6
7
8
9
10
11
12
13+
LTR
STR
Vacant
Secondary
Commercial
Location 2
Single-Family Detatched
Single Family Attached
Multi-Unit
Condo
Manufactured Home
Other
1
2
3
4
5
6
7
8
9
10
11
12
13+
LTR
STR
Vacant
Secondary
Commercial
Location 3
Single-Family Detatched
Single Family Attached
Multi-Unit
Condo
Manufactured Home
Other
1
2
3
4
5
6
7
8
9
10
11
12
13+
LTR
STR
Vacant
Secondary
Commercial
Location 4
Single-Family Detatched
Single Family Attached
Multi-Unit
Condo
Manufactured Home
Other
1
2
3
4
5
6
7
8
9
10
11
12
13+
LTR
STR
Vacant
Secondary
Commercial
Would you like to add Mortgagee Info at this time?
Yes
No
Mortgage Info
Would you like to provide detailed information about your home? (Square footage, # of Bathrooms, etc.) Unless this is a new-build, we can likely pull information from reports.
Yes
No
Please have agent contact me if home information is not automatically pulled from reports
Home Information
Further Information
Do you use a Third-Party Property Manager?
Yes
No
Undecided/Unsure
Select All Applicable Exposures
Duplex/Triplex/Row Home
Condo Unit
Under Construction/Renovation
Swimming Pool (gated)
Swimming Pool (no gate)
Diving Board/Slide
Hot Tub/Spa
Secure Community
Historical Registry
Secondary Heat
Local Fire Alarm
Central Fire Alarm
Local Burglar Alarm
Central Burglar Alarm
Fuse Box
Other
Describe which locations have which Applicable Exposures
Coverage Options
I would like to select my options
Please match my current policy
I need guidance on coverage options
Coverage Information
Additional Coverage Options
Water Backup
Earthquake
Business in Residence
Ordinance or Law
Identity Recovery
Sinkhole
Other
Further Details (if needed)
Back
Next
Save for Later
Life Insurance
Life Insurance typically requires an in-depth conversation. If you are not the agent handling the quote/policy, please set an appointment for the desired agent.
Products to Quote
Payment Frequency Preference
Please Select
Monthly
Quarterly
Semi-Annual
Annual
Undecided
Height
Weight
Expected Rating Class
Preferred Best Non-Tobacco
Preferred Non-Tobacco
Standard Plus Non-Tobacco
Standard Non-Tobacco
Standard Tobacco
Preferred Tobacco
Other
Please list all underwriting concerns
Please give further description/information needed for quote(s)
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Provide any additional information which may be needed
Save for Later
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