Freedom Insurance Group Quote Form
By filling out this form, you consent to be contacted by Freedom Insurance Group via text and/or phone call.
Contact Information
Name
*
First Name
Last Name
Suffix
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Sex
*
Female
Male
Non-Binary
Please select the type of quote. (Check all that apply)
*
Auto
Home
Life
Pet
Renters
Other
Other type of insurance.
*
Please include as much information as possible.
Auto Insurance
Driver's License Status (check all that apply)
I don't have a driver's license
My driver's license is suspended or revoked
I need SR22
I don't own a car, but still need insurance
I have a valid driver's license
Driver's License State
*
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Driver's License Number
*
A quote cannot be completed without this information.
Have you had any tickets or accidents in the last five (5) years?
*
Upload most recent Declaration Page
Browse Files
Drag and drop files here
Choose a file
You do not need to complete any other information if your declaration page is uploaded.
Cancel
of
Are any coverages or vehicles different from the current declaration page?
Optional
Current Provider
Auto Insurance
Who is your current insurance company?
*
I don't have insurance right now
Company Name
When did your policy cancel?
/
Month
/
Day
Year
Date
When does your policy renew?
*
/
Month
/
Day
Year
Date
How do you pay your insurance premium?
*
Please Select
Paid in full
Monthly-Automatically from an account
Monthly-Automatically from a credit or debit card
Monthly-Manually
Do you have additional household members and/or drivers to include?
*
Yes
No
Unsure
Additional Driver(s)
*
Please explain.
*
Vehicle Information
*
Optional Coverages
Check all that apply.
*
I rent.
I own my home.
I own properties which are rented to others.
I have other properties for personal use.
Other
Home Insurance
Renters Insurance
Current Provider
Property Insurance
Who is your current insurance company?
*
I don't have insurance right now.
Company Name (Text box will appear once selected.)
How do you pay your insurance premium?
*
Please Select
Paid in full
Paid by the mortgage company
Monthly-Automatically from an account
Monthly-Automatically from a credit or debit card
Monthly-Manually
Upload most recent Declaration Page
Browse Files
Drag and drop files here
Choose a file
You do not need to complete any other information if your declaration page is uploaded.
Cancel
of
How much personal property coverage do you currently have or need?
*
$10,000 - $20,000
$25,000 - $50,000
$50,000 - $100,000
More than $100,000
I'm not sure.
Does your landlord require you to have insurance?
*
Please Select
No
Yes
How many units are in your building?
*
Please Select
Single Family Home
Duplex
Triplex
4 units
5+
Property Information
Check any that apply.
*
I'm purchasing a new home.
My home is being built.
I have a Rent-To-Own contract.
None
When do you expect to close?
*
/
Month
/
Day
Year
Date
Paste the link, if the property is listed online.
Upload the property details sheet.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Purchase date?
/
Month
/
Day
Year
Date
I have additional household members to add.
*
No
Yes
Additional Household Members
Property Details
Life Insurance
What do you want life insurance to do for you? (Select all that apply)
*
I want to help my family with funeral expenses and some financial support
I want my family to be fully taken care of for years after I pass
I want my mortgage to be covered
I’m not sure what I want from it
Death Benefit Amount
*
$150k or Less
$250k
$500k
$1 Million or more
Unsure
Insured Information
Check all that apply.
*
I want insurance for myself.
I want insurance for someone else.
Are you a U.S. Citizen?
*
Please Select
Yes
No
Other
Sex
*
Please Select
Male
Female
Place of Birth
City and State Or Country if Outside US
Height
*
Weight
*
Tobacco Use
*
Please Select
Yes
No
Occupation/Title
Est. Income
Primary Beneficiary
First Name
Last Name
Medical Issues
*
Cancer
Heart
Diabetes
AIDS/HIV
Other
None
Describe Medical Issues
Date of Diagnoses, Type, Other Relevant Information
Any Medications Used
Name of Prescription, Dosage, Frequency
Person to be insured
*
Pet Insurance
Pet Information
Pet Type
*
Dog
Cat
Pet Gender
*
Male
Female
Pet Age
*
Please Select
Under 8 Weeks
8 Weeks to 11 Months
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 + years
Has any veterinarian conducted a comprehensive physical examination on the pet within the last 12 months?
*
Yes
No
Do you have additional pets to add?
*
Yes
No
Additional Pet Information
Additional Information
Highest level of education completed?
Please Select
High School Diploma or Equivalent (GED, HSED, etc)
Vocational or Technical Certificate
Some College
Associate's Degree
Bachelor's Degree
Master's Degree
Professional Doctorate (MD, JD, DDS, etc)
Doctorate (PH.D, Ed.D, etc)
Some carriers offer a discount.
Occupation and Employer
Some carriers offer a discount.
Other Information
Anything that might be relevant for your quote.
How did you hear about us?
*
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