Auto/Home Quote
Please fill out this form to submit a request for Insurance with our Agency. If you have additional questions, you can call Ken Pfister at 240-580-1166.
Type of Insurance Requested (Check All That Apply):
*
Auto
Home
Auto & Home
Renters
Landlord (Rental Property)
Mobile Home
Mobile Home Renters
Other
Name
*
First Name
Last Name
Best Phone Number to Contact You:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Type:
Please Select
Mobile
Home
Work
Other
Primary Email Address:
*
example@example.com
Birthdate:
*
-
Month
-
Day
Year
Date
Street Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is mailing address different than street address?:
*
Yes
No
Mailing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Length of Time at Current Address:
*
Less than 1 year
1 to 3 years
3 to 5 years
More than 5 years
Enter Previous Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status:
*
Single
Married
Divorced
Separated
Widowed
Spouse's Name:
*
Spouse's Birthdate:
*
-
Month
-
Day
Year
Occupation:
*
Total Number of People in Household:
*
List Anyone in Household who has their own insurance and/or will not be on your policy:
AUTO INSURANCE
Please provide auto insurance information in this section.
Insurance Status:
*
Currently Insured
Current Not Insured
First Time owning a vehicle
Currently on Family Member policy
Other
Date Current Insurance Renews:
-
Month
-
Day
Year
Date
Total Number of Vehicles to be insured. (If more than 4 vehicles, upload copies of VIN numbers in "Upload Current Insurance Documents in this form."):
*
Upload Picture of Drivers Licenses for ALL Drivers who will be driving:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload Current Insurance Documents:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Enter 17 Digit VIN Number of Vehicle Number 1 to be insured:
*
Enter 17 Digit VIN Number of Vehicle Number 2 to be insured:
*
Enter 17 Digit VIN Number of Vehicle Number 3 to be insured:
*
Enter 17 Digit VIN Number of Vehicle Number 4 to be insured:
*
Vehicle(s) equipped with Blind Spot Warning?:
No
Yes
Unknown
Current Cost of Insurance (Enter Monthly amount or full term amount):
List any violations or accidents in the last 3 years:
Coverage Type:
*
Liability Only
Full Coverage
Select vehicle #1 deductibles:
*
$100 Comprehensive, $100 Collision
$250 Comprehensive, $250 Collision
$250 Comprehensive, $500 Collision
$500 Comprehensive, $500 Collision
$1000 Comprehensive, $1000 Collision
$100 Comprehensive only
$250 Comprehensive only
$500 Comprehensive only
$1000 Comprehensive only
Liability Only
Other
Select vehicle #2 deductibles:
*
$100 Comprehensive, $100 Collision
$250 Comprehensive, $250 Collision
$250 Comprehensive, $500 Collision
$500 Comprehensive, $500 Collision
$1000 Comprehensive, $1000 Collision
$100 Comprehensive only
$250 Comprehensive only
$500 Comprehensive only
$1000 Comprehensive only
Liability Only
Other
Select vehicle #3 deductibles:
*
$100 Comprehensive, $100 Collision
$250 Comprehensive, $250 Collision
$250 Comprehensive, $500 Collision
$500 Comprehensive, $500 Collision
$1000 Comprehensive, $1000 Collision
$100 Comprehensive only
$250 Comprehensive only
$500 Comprehensive only
$1000 Comprehensive only
Liability Only
Other
Select vehicle #4 deductibles:
*
$100 Comprehensive, $100 Collision
$250 Comprehensive, $250 Collision
$250 Comprehensive, $500 Collision
$500 Comprehensive, $500 Collision
$1000 Comprehensive, $1000 Collision
$100 Comprehensive only
$250 Comprehensive only
$500 Comprehensive only
$1000 Comprehensive only
Liability Only
Other
Payment Method:
*
Monthly - Checking Account
Monthly - Debit/Credit Card
Pay Every 6 months
Pay Every 12 months
Quarterly
Other
I currently:
*
Own my home
Am purchasing a new home
Own a condo
Rent an apartment
Rent my home
Rent a condo
Rent a manufactured home
Own a Manufactured home
Live with parents or family
Other
HOME INSURANCE
Please provide additional information for the home.
Is Insurance to be Escrowed?
Yes
No
Settlement Date:
-
Month
-
Day
Year
Date
Name and Phone Number of Mortgage Company Representative:
Address of New Home:
Current Cost Home Insurance Now:
Roof Material:
Shingle
Metal
Tile
Other
Exterior:
Vinyl Siding
Metal Siding
Brick
Stucco
Concrete
Imitation Stone
Asbestos Shingle
Log Siding
Stone
Wood
Other
Primary Source of Heat:
Electric
Gas
Gas Hot Water
Heat Pump
Radiator Heat
Wood Stove
Other
Year of Roof Replacement:
*
Select All that apply:
None of these
Swimming Pool
Hot Tub
Trampoline
Detached Garage(s)
Detached Utility Buildings
Gazebos
Other
Any Dogs?:
Yes
No
Any Bite History:
Yes
No
Provide Type of Dog, Date and Additional Details of Incident:
Renters Insurance
Please provide additional information for the renter's coverage.
Select the Amount of Personal Property you wish to have covered:
15k
20k
25k
30k
More Than 30k
Other
Number of Units in Your Building:
Please provide any additional comments here:
Who referred you to us?"
Alan Chichester
Bill Logsdon
Khloe Yost
Laura Yost
Linda McGill
Michael Mackereth
Internet Search
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Other
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