Vehicle & Home Insurance Request for Quote
Person & Contact Details
How did you hear about us?
Please Select
A customer referred me
Google
Website
Saw Our Sign
George Restaurant
Mortgage Lender Referred Me
My Relator Referred Me
Name
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First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Do We have permission to communicate via text with you at this number? By selecting Yes, you agree to receive text messages from Spitzer Insurance Agency . Message frequency may vary. Message and data rates may apply. Text HELP for assistance. To opt-out at any time, reply STOP.
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Yes
No
Date of Birth (Required to Quote)
*
-
Month
-
Day
Year
Martial Status
Please Select
Single
Married
Divorced
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Existing Insurance
Do you have prior insurance for at least 6 months with no lapse?
*
Yes
No
What is the desired effective date?
-
Month
-
Day
Year
Are there additional drivers? If so, what is their name and date of birth?
We give discounts for certain occupations...What do you do for a living? (If Retired, what occupation are you retired from?)
Current Insurer
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Vehicle Details
We require some information about your vehicle to do an accurate quote.
What is the year, make & model of EACH vehicle you would like insured?
*
Example: 21 Ford F150/ 17 Toyota Prius
Do you want Comprehsnive Coverage on your vehicles?
Yes
No
Do you want Collision Coverage on your vehicles?
Yes
No
Do you want Rental Coverage?
Yes
No
Do you want Glass Coverage?
Yes
No
Do you want towing coverage?
Yes
No
Is your Vehicle used for Private or/and Business?
Private only
Business only
Private and Business
Do you need to insure extras? Please add what extras you would like to insure, with the value.
*
Example: Custom Wheels
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Renters Insurance
How much coverage are you wanting for all of your personal property (clothing, furniture, tvs, etc)?
Example: $20,000
How much coverage are you wanting for liability portection?
Please Select
$100,000
$300,000
$500,000
$1,000,000
Any additional notes you would like us to know?
Example: Extra Riders - Water Back up, Service Lines
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Recreational Vehicle Quote Form
Which recreational products would you like to insure?
Motor Home
Travel Trailer
Boat
ATV
Motorcycle
Golf Cart
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Motor Home/ Travel Trailer
(click next if not applicable)
VIN
Year, Make & Model
Length
Value
Coverage Requested
Years Experience driving this type of vehicle?
Any additional notes you would like us to know?
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Boat
(click next if not applicable)
HIN
Boat Year, Make & Model
Motor Year & Make
Type of Motor
Please Select
Inboard
Outboard
Other
Horsepower
Length
Value Boat & Motor
Trailer Information
Trailer Value
Months Boat is used in water
Years of experience operating watercrafts
Hull Material
Example - Fiberglass, Aluminum
Max Speed
Number of Engines
Coastal or inland water use?
Any additional notes you would like us to know?
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ATV/Motorcycle
(click next if not applicable)
VIN
Year, Make & Model
How many CCs?
Value
Is the unit licensed for on road use?
Please Select
Yes
No
Requested Coverage
Has the unit been supercharged?
How many years of experience operation motoryclces?
Any additional notes you would like us to know?
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Golf Cart
(click next if not applicable)
Is the unit license for on road use?
Please Select
Yes
No
Year, Make & Model
What is the current market value?
How many months a year is the unit used?
Any additional notes you would like us to know?
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Please upload current declaration page if available.
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