Home & Auto Proposal
Please complete the fields below to the best of your knowledge. If you do not know the information please leave the field blank.
Reply Email
example@example.com
Agency Name
Policy Type
Monday.com Title
Customer First Name
*
Customer Last Name
*
Customer Full Name
Customer Birthdate
*
-
Month
-
Day
Year
Date Picker Icon
Customer Email
*
example@example.com
Customer Phone Number
*
Please enter a valid phone number.
Are You Married (If you need auto coverage, we will need your and your spouses drivers license numbers, so please have those handy).
*
No
Yes
Spouse's First Name
*
Spouse's Last Name
*
Spouse's Full Name
Spouse's Date of Birth
*
-
Month
-
Day
Year
Date
Desired Effective Date You Would Like Coverage To Start
-
Month
-
Day
Year
Date
Do you have a dog(s)
*
No
Yes
Please describe the breed(s). (Certain breeds are a problem for insurance companies. Be sure to disclose yours). P.S - What's your dog's name :)
Did you have any claim(s) in the past 5 years?
*
No
Yes
Please describe the claim(s).
Are You Seeking a Homeowners Policy or Renter's Policy
*
Homeowner's Policy
Renter's Policy
Condo Policy
Is This A New Property Purchase?
*
Yes
No
What Is Your Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Insurance Carrier (If none, type "NA" or "New Property Purchase")
*
Property Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
What Is Your Desired Deductible?
*
Please Select
$1,000
$2,500
$5,000
$10,000
Select Any Protective Device You Have In The Home
*
Back Up Generator
Flow Logic Water Shut Off
Temperature Sensor Monitoring
Fire/Burglar Alarm Paid Monitoring
Other
Is There A Mortgage On The Property
Yes
No
What Is The Name & Contact Information Of The Lender
*
Year Built Of Your Home
Year Property Was Purchased
Approximate Finished Square Footage Above Ground (Not Including Basement)
What Is The Age Of The Roof. (Roofs Over 20 Years Old May Present Underwriting Challenges, Please Make Sure Roof Age Is Accurate).
*
Does the home have a wood burning stove or fireplace?
*
No
Yes
Please describe the stove. (Ex: pellet stove, wood burning fireplace etc.)
Foundation Type
Crawl Space
Slab
Full Basement
Are You Concerned About Water Backing Up Into The Basement
*
Yes
No
What Limit Of Insurance Would You Like To Have In The Event Of Water Backup In The Basement
*
$10,000
$25,000
$50,000
Higher
Is Any Part Of The Basement Finished?
Yes
No
Approximate Square Footage Of Finished Area In Basement
Does the basement have a sump pump?
*
Yes
No
I'm Not Sure
Does The Property Have A Garage?
No
Yes - Attached Garage
Yes - Detached Garage
Are There Any Other Structures On The Property?
Yes
No
Please Describe The Other Structures
What Type(s) Of Siding Does The Home Have?
Brick
Vinyl
Wood
Stucco
Other
What Type(s) of Siding does the Home Have?
Ex: Brick, Vinyl, Wood, Stucco, Other Types
Do you have the ability to Upload / Take a photo of your home right now to verify the materials of roof and siding construction?* (Note: If your home is over $500,000 we will need photos of all four sides of your home).
*
Yes
No
Please Upload The Photo(s)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
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Does The Property Have A Pool?
No
Yes - In Ground Pool
Yes - Above Ground Pool
Does the pool have a fence with a locked gate and/or automatic safety cover?
Yes
No
Does the pool have a locked gate?
Yes
No
Has There Been Any Plumbing Updates Done To The Property (Remodeling)?
No
Yes
Please Describe The Update And What Year The Update Occurred?
Has There Been Any Electrical Updates Done To The Property (Remodeling)?
No
Yes
Please Describe The Update And What Year The Update Occurred?
Has There Been Any HVAC Updates Done To The Property (Have You Replaced An Air Conditioner Or Furnace)?
No
Yes
Please Describe The Update And What Year The Update Occurred?
Have You Replaced The Roof On Your Home Since It Was Built?
No
Yes
Please Describe The Update And What Year The Update Occurred (Roofs Over 20 Years Old May Present Underwriting Challenges, Please Make Sure Your Roof Age Is Accurate).
Has There Been Any Other Updates Done To The Property?
No
Yes
Please Describe The Update And What Year The Update Occurred?
Do You Have Other Owned Rental Properties Or Vacation Homes?
*
Yes
No
Do You Desire Personal Auto Coverage?
*
Yes
No
What Is Your Driver's License Number
*
Drivers License State (Abbreviation - ie WI or IL)
*
Are There Other Household Driver's Besides Yourself (ie - Child Or Other Relative Regularly Driving Your Vehicle)?
*
Yes
No
Please provide DL for you and your spouse as well as the DL Number and **DATE OF BIRTH** for any other additional listed drivers in the home.
*
Ex: John Smith, 3-21-85, J540-887755, WI
Do you have anyone living in your home (household member) age 15 or older that does not have a driver's license yet?
*
No
Yes (Some insurance companies may charge for this unlicensed driver as a household member exposure)
Do You Desire Rental Reimbursement Coverage? (In The Event Of A Claim, Insurance May Pay For Car Rental Expenses).
Yes
No
Do You Desire Roadside Assistance Coverage?
Yes
No
What Is Your Desired Deductible
Please Select
$500
$1000
$1500
$2000
$2500
How Many Vehicles Need Coverage?
*
1
2
3
4
Vehicle 1 Year
*
Vehicle 1 Make & Model
*
Would You Like To Take A Picture Of The VIN # Or Enter It Manually For Vehicle 1?
*
Take A Picture
Enter Manually
Upload An Image Of The VIN # For Vehicle 1
*
Browse Files
Drag and drop files here
Choose a file
Cancel
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Vehicle 1 VIN #
*
Vehicle 2 Year
*
Vehicle 2 Make & Model
*
Would You Like To Take A Picture Of The VIN # Or Enter It Manually For Vehicle 2?
*
Take A Picture
Enter Manually
Upload An Image Of The VIN # For Vehicle 2
*
Browse Files
Drag and drop files here
Choose a file
Cancel
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Vehicle 2 VIN #
*
Vehicle 3 Year
*
Vehicle 3 Make & Model
*
Would You Like To Take A Picture Of The VIN # Or Enter It Manually For Vehicle 3?
*
Take A Picture
Enter Manually
Upload An Image Of The VIN # For Vehicle 3
*
Browse Files
Drag and drop files here
Choose a file
Cancel
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Vehicle 3 VIN #
*
Vehicle 4 Year
*
Vehicle 4 Make & Model
*
Would You Like To Take A Picture Of The VIN # Or Enter It Manually For Vehicle 4?
*
Take A Picture
Enter Manually
Upload An Image Of The VIN # For Vehicle 4
*
Browse Files
Drag and drop files here
Choose a file
Cancel
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Vehicle 4 VIN #
*
Do you have any non-auto vehicles that you would like covered (ATV, Motorcycle, Boat, Snowmobile, Motorhome, Golf Cart, Trailer, Moped etc).
Yes
No
Please describe the vehicle(s) and include VIN or Serial # if applicable.
Make, Model, Year
Do you have any Jewelry, Fine Art, or Other Collectibles you would like covered? In order to be insured for 'losing' a piece of jewelry, it does have to be listed/scheduled. (It's always good to track down your appraisals - we may need current appraisal.)
*
Yes
No
Please describe the item(s) and estimated values.
Ex: Womens Engagement Ring White Gold 2 1.6Kt 2.2 carat princess cut diamond color v Clarity xiii Value: $22,000
Do You Desire An Umbrella Liability Policy
Yes
No
What Is Your Desired Amount Of Excess Liability?
Please Select
$1Million
$2Million
$3Million
$4Million
$5Million
$6Million
$7Million
$8Million
$9Million
$10Million
Is there anything else you are concerned about insuring that was not mentioned in the questions above?
If you wish to include any images of your ID cards, Dec Pages, or Policy Pages, Jewelry Appraisals please upload them here. (If you have more than 4 vehicles, this is where you can add images of their corresponding VIN #s).
Browse Files
Drag and drop files here
Choose a file
Cancel
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Are You A Current Interstate Customer
*
Yes
No
How did you hear about Interstate Insurance?
*
Customer / Prospect
Submit
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