Requote Request

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

What policies do you already have insured in our agency?* This field is required.This form is currently designed for home and auto updates and remarketing purposes only

Auto

Home / Condo

4

Approximately how many miles do you drive each vehicle in a year? Average usage is around 12-15k a year. Discounts available for low mileage vehicles. 2020 Honda 10k, 2022 Toyota 12k, etc.

5

Do any vehicles have aftermarket custom parts and equipment valued over $1,000?Custom wheels, canopy, audio/visual equipment, custom paint, etc.

YESNO

6

Provide a brief description of the individual custom parts and equipment items as well as a ballpark on the value.

7

Do you drive for Uber, Lyft, Doordash or any other ridesharing or delivery services?* This field is required.

YESNO

8

Please clarify what service you drive for. * This field is required.

9

Are there any licensed drivers living in your home or that have regular access to drive your vehicle that we do not already have listed as a household member or driver on the policy?* This field is required.

YESNO

10

How many additional licensed drivers living in your home or have regular access to drive your vehicles that are not already listed on your policy?* This field is required.If so, how many additional drivers are there?

11

Details on additional driver* This field is required.

What is your relationship to this other driver (parent, child, relative, significant other, roommate, etc.)

First / Last Name

Birthday

Any notes about this driver you wanted to share. For example, do they have their own car/insurance elsewhere?

12

Details on additional driver* This field is required.

What is your relationship to this other driver (parent, child, relative, significant other, roommate, etc.)

First / Last Name

Birthday

Any notes about this driver you wanted to share. For example, do they have their own car/insurance elsewhere?

13

Details on additional driver* This field is required.

What is your relationship to this other driver (parent, child, relative, significant other, roommate, etc.)

First / Last Name

Birthday

Any notes about this driver you wanted to share. For example, do they have their own car/insurance elsewhere?

14

Details on additional driver* This field is required.

What is your relationship to this other driver (parent, child, relative, significant other, roommate, etc.)

First / Last Name

Birthday

Any notes about this driver you wanted to share. For example, do they have their own car/insurance elsewhere?

15

What year was the roof last replaced?* This field is required.If unknown, provide your best estimate.

16

Do you have a dog or farm animal(s)?* This field is required.

Dog

Farm Animals (goat, sheep, horses, chickens, etc.)

None

17

Please let us know how many dogs you have and what breed(s)* This field is required.

18

Is there any bite history with your dogs?* This field is required.If yes, provide more details

19

Please let us know what type of farm animals you have and how many of each. * This field is required.

20

Is there any farm income generated from the animals?* This field is required.Selling eggs, wool, meat, etc.

21

Do you operate a business from home?* This field is required.

YESNO

22

Please provide more details on the in home business. * This field is required.

What type of business is it? More detail the better.

Do you have advertising on your properties exterior?

Is there any client or employee foot traffic on your property?

Do you operate from main home or a detached structure?

23

Do you plan to rent out all or a portion of your primary or secondary residence to a long term or short term tenant (airbnb, vrbo, etc.)* This field is required.

NO rental exposure

Long Term (Home is owner occupied but renting out extra bedroom, basement, adu, etc. to long term tenant)

Short Term (Owner vacates and rents out entire home for short term rentals)

Short Term (Owner occupied but renting out a portion of home like an ADU, basement suite, etc. to short term tenants)

24

Is the home titled in your personal names or an entity such as a Trust or LLC?* This field is required.

Personal Name(s)

Trust

LLC

Other

25

Please provide the name and purpose of the entity so we can add accordingly and verify carrier guidelines.* This field is required.

26

Have you completed any significant renovations or home modifications we should be aware of that may require additional coverage?* This field is required.Added an addition, finished a basement, added a bathroom, built a detached garage etc.)

YESNO

27

Please provide a description of the home renovation or modifications. * This field is required.

28

Have you ever been notified of any of the following property conditions?* This field is required.Select all that apply

Knob and Tube wiring

Aluminum branch wiring

Federal Pacific Electrical Panel

Zinsco Electrical Panel

Polybutylene Plumbing

None of the above

Unsure

29

Which best describes what you'd like us to focus on?* This field is required.

Confirm my current policies are still competitive and review alternative options if meaningful savings are available

Explore ways to reduce premium, including possible deductible or coverage adjustments

Review coverage recommendations and protection gaps

Discuss recent changes that may impact my insurance needs

30

Which approaches would you be most open to discussing if they help reduce premium?* This field is required.Select all that apply

Higher Deductibles

Reviewing alternative carrier option

Adjusting / removing optional coverages currently in place

Bundling additional policies

General recommendations from your team

No major changes preferred

31

Insurance Score Update - Current Carrier(s)* This field is required.We may be able to request that your current carrier update the insurance score on file, to see if an improved score can help lower your premium. Insurance scores are also used when quoting most new business, so this simply applies the same check to your existing policy. We recommend this step because it sometimes allows your current carrier to lower your premium without needing to switch companies. Insurance scores are based on credit-related factors, but checking yours is a soft inquiry and does not affect your credit score. We will only submit this request when both of the following are true: Your carrier allows us to request the update directly on your behalf, and We can confirm your premium will not increase even if your updated score turns out to be lower. If either of those isn't the case, we won't submit it using this authorization — we'll follow up with you directly to explain and ask how you'd like to proceed. Would you like us to request an updated insurance score on your current policy(ies)?

YES - I Authorize my Insurance carrier to request an updated insurance score on my current policy(ies)

NO - Please do not request an updated insurance score at this time

32

Enter full name to confirm re-score authorization* This field is required.

First Name

Last Name

33

Date

34

Is there anything else you would like our team to review or be aware of?