Request A Quote
Personal Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Seeking a quote for:
*
Please Select
Auto Insurance
Home or Condo Insurance
RV, Boat, Motorcycle or other specialty vehicles
Life Insurance
Commercial Insurance
Renter's Insurance
Home or Condo Insurance
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupancy
Primary residence
Secondary Home
Tenant occupied
Current Insurance Company
Renewal Date
Year built
Construction type
Frame
Solid brick
Mobile/manufactured
Town Home
Does your home have a basement?
No
Yes, unfinished
Yes, finished
Square Footage (NOT INCLUDING BASEMENT)
Number of stories
Primary heat
Natural gas
Propane
Roof type (metal, asphalt, etc.)
Year roof was replaced
Does your home have a garage? If so, how many cars and is it attached or detached?
Exterior wall construction (stucco, siding, brick, etc)
Number of Bathrooms
Is there a fireplace in the home?
Yes
No
Any wood stoves?
Yes
No
Any outbuildings?
Yes
No
Is there a mortgage on the home? If so, are you the payor?
Auto Insurance
Garaging Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Driver Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Drivers License Number
Employment Status
Are you employed? If so, what is your job title?
Add another driver? (1)
Please Select
Yes
No
Add Another Driver
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Drivers License Number
Employment Status
Are you employed? If so, what is your job title?
Add another driver? (2)
Please Select
Yes
No
Add Another Driver
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Drivers License Number
Employment Status
Are you employed? If so, what is your title?
Add another driver? (3)
Please Select
Yes
No
Add Another Driver
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Drivers License Number
Employment Status
Are you employed? If so, what is your title?
Vehicle Information
Vehicle VIN#
Make, Model, and Year of vehicle you need insured
I would like:
Please Select
Comp & Collision
Liability Only
I need advice for selecting coverage
Is the use of the vehicle for commute or pleasure? If commute, how far is it driven each day for work?
Add another vehicle? (1)
Please Select
Yes
No
Add Another Vehicle
Vehicle VIN#
Make, Model, and Year of vehicle you need insured
I would like:
Please Select
Comp & Collision
Liability Only
I need advice for selecting coverage
Is the use of the vehicle for commute or pleasure? If commute, how far is it driven each day for work?
Add another vehicle? (2)
Please Select
Yes
No
Add Another Vehicle
Vehicle VIN#
Make, Model, and Year of vehicle you need insured
I would like:
Please Select
Comp & Collision
Liability Only
I need advice for selecting coverage
Is the use of the vehicle for commute or pleasure? If commute, how far is it driven each day for work?
Add another vehicle? (3)
Please Select
Yes
No
Add Another Vehicle
Vehicle VIN#
Make, Model, and Year of vehicle you need insured
I would like:
Please Select
Comp & Collision
Liability Only
I need advice for selecting coverage
Is the use of the vehicle for commute or pleasure? If commute, how far is it driven each day for work?
Add another vehicle? (4)
Please Select
Yes
No
Add Another Vehicle
Vehicle VIN#
Make, Model, and Year of vehicle you need insured
I would like:
Please Select
Comp & Collision
Liability Only
I need advice for selecting coverage
Is the use of the vehicle for commute or pleasure? If commute, how far is it driven each day for work?
Current coverage Information
Renewal Date with current insurance company
-
Month
-
Day
Year
Date
Current liability limits
Have you had any at-fault accidents in the last 5 years?
Yes
No
Have you received any tickets within the last 3 years?
Yes
No
RV, Boat, Motorcycle, or other specialty vehicles
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Drivers License Number
Employment Status
Year, make, & Model
VIN
Is this vehicle currently Insured?
Please Select
Yes
No
Feedback
How did you hear about Schaefermeyer Insurance?
*
Please Select
Internet search
Referral
I am a current customer
Social Media
Other
If you were referred, who can we thank?
Please include any additional information you feel is relevant
Submit
Should be Empty: