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Personal Lines Quote Form
How did you hear about us?
*
Please Select
Google
Facebook
Other Social Media
A Customer Referred Me
Newspaper Ad
Saw Your Sign
Met An Agent At An Event
My Mortgage Lender Referred Me
My Realtor Referred Me
Are you working with a current employee in our agency?
Please Select
Roxie Whigham
PK Kelley
Clarissa Franco
Diana Flores
Jennifer Halliburton
Marcy Perez
Susan O'Connor
Nate Fedor
Pam Young
Other/Not working with anyone
What type of insurance quote are you requesting?
Home
Auto
Mobile/Manufactured Home
Renters
Motor Home/Travel Trailer
Boat
ATV/Motorcycle
Individual Health
Life
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Marital Status
Please Select
Married
Single
Divorced
Occupation (If Retired what occupation did you retire from?)
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?
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is Mailing Address the same as the physical address?
Yes
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Insured
First Name
Last Name
Secondary Insured's Date of Birth
/
Month
/
Day
Year
Date
Desired Coverage Start Date
*
/
Month
/
Day
Year
Date
Home Information
What is your current occupation? (QUALIFYING DISCOUNT)
What is your level of education? (QUALIFYING DISCOUNTS)
Please Select
High School Diploma
College Degree
Driver's License Number (QUALIFYING DISCOUNTS)
Social Security Number
Spouse's Name
First Name
Last Name
Spouse's Phone Number
Please enter a valid phone number.
Spouse's Email
example@example.com
Spouse's Birthdate
-
Month
-
Day
Year
Date
Driver's License Number (QUALIFYING DISCOUNTS)
Social Security Number
What is your spouse's current occupation? (QUALIFYING DISCOUNT)
What is your level of education? (QUALIFYING DISCOUNTS)
Please Select
High School Diploma
College Degree
What is the intended occupancy of the home?
*
Please Select
Owner Occupied
Owner Occupied Secondary location
Rented to others full time (investment property)
Rented to others on short term (VRBO/AirBNB)
Vacant
Is this home a new purchase?
*
Please Select
Yes
No
If not a new purchase, who is your home currently insured with?
What is the desired Dwelling coverage amount?
*
What year was your home built?
What is the square footage of your home?
How many bedrooms?
*
How many bathrooms?
*
How many stories is your home?
Roof Material
Please Select
Shingles
Metal
Tile
Other
What year was your roof last replaced?
*
Outside Construction type
*
Please Select
Brick Veneer
Stucco
Vinyl Siding
Clapboard Siding
Wood
Asbestos
Other
What is the foundation type of the home?
*
Please Select
Slab
Crawlspace
Have you had any homeowner claims in the last 5 years? (please enter date and details)
Do you have the following?
*
Yes
No
Monitored Central Burglar / Fire Alarm?
Do you have a fireplace?
Have you had your home cancelled or non- renewed?
Do you have solar panels?
Do you have any dogs with a bite history?
Do you have a swimming pool?
Do you have a trampoline?
Do you have any agriculture exposure? (cows/goats/horses)
Important information to relay regarding quotes:
Auto Information
Primary Insured's Social Security Number
Primary Insured's Drivers License Number
Secondary Insured's Social Security Number
Secondary Insured's Drivers License Number
Additional Driver Information
Does any driver require an SR22?
Yes
No
Vehicle Information
Tickets/Accidents (Last 3 Years)
How long have you lived at this residence?
*
Do you currently own a home?
Yes
No
Are you currently insured?
*
Yes
No
If yes, what carrier & How long have you been insured with them?
What were your prior liability limits on your last auto policy?
Example 100/300/100 or 250/500/250 etc
Mobile/Manufactured Home Information
SSN #
Desired Coverage Limit/Loan Value
Is this home a new purchase?
*
Please Select
Yes
No
How is the home occupied?
*
Please Select
Owner Occupied
Rented to Others
Owner Occupied part time and rented to others part time
Vacant
What year was your home built?
*
How much personal property do you need covered?
*
Estimated total dollar amount for all personal items in the home.
Serial Number
Make & Model of Home
What was the purchase date of your home? (If new purchase what is anticipated closing date)
*
What is the Length & Width of your home?
*
In Feet and Inches
What year is your roof?
*
What Type of Home?
*
Please Select
Single Wide
Double Wide
Triple Wide
Roof Material
*
Please Select
Shingles
Metal
Tile
Rubber
Other
Plumbing Type
*
Please Select
Copper
Galvanized
PEX
Polybutylene
PVC
Monitored Central Burglar Alarm
*
Yes
No
If your home on a permanent foundation?
*
Yes
No
Monitored Central Fire Alarm
Yes
No
Do you have any attached structures? (Add details in the notes section)
*
Yes
No
Do you have any detached structures? (Add details in the notes section)
*
Yes
No
Is your home on your own private property or in a park?
*
My Property
Park Community
A Fire Hydrant outside within 1000 Feet of your home
*
Yes
No
Do you live in a gated community?
*
Yes
No
Do you have a wood burning stove?
*
Yes
No
Have you filed for bankruptcy, Foreclosure, Repossession or Short Sale in the past 5 years?
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Yes
No
Have you had your home insurance canceled, non-renewed or denied coverage?
*
Yes
No
Are there any dogs with bite history?
*
Yes
No
What type of flooring do you have in your house? If multiple, please give an estimate on % of each kind.
*
If currently insured, who is your current carrier?
*
Renters Information
Are you a Current Client?
*
Please Select
Yes
No
SSN #
Home Type
*
Please Select
Single Family Home
Condo/ Townhome with HOA that has insurance for the exterior
Condo/ Townhome NO HOA Insurance
Apartment
What is the square footage of your home?
*
How many stories is your home?
*
Do you live in a gated community?
Yes
No
Do you have a fire place?
Yes
No
Have you filed for bankruptcy, Foreclosure, Repossession or Short Sale in the past 5 years?
Yes
No
Are there any dogs with bite history?
Yes
No
Do you have a pool?
Yes
No
Who is your current insurance carrier?
Motorhome/Travel Trailer Information
Vin#
*
Year
Make
Model
Value
Length
Weight
# of slides
Coverages Requested?
Do you live in this vehicle full time?
Years of experience driving this type of vehicle?
Are you a member of of an RV association?
Boat Information
HIN
Year
Make
Model
Motor Info
Horsepower
Length
Value
Motor Style
Inboard
Outboard
Other
Coverages Requested?
Would you like environmental coverage?
Trailer Information
Length of time boat is in the water
Years of experience driving boats?
Hull material
Fuel type
Power type
Max speed
Number of engines
Coastal or inland water use?
ATV/Motorcycle Information
Vin/Serial #
Year
Make
Model
How many CCs?
Value
Driver Information
Requested coverages
Do you need Comprehensive / Collision
Comprehensive
Collision
Additional equipment exceeding $3,000
Has it been converted to a trike?
Has it been supercharged?
Is your vehicle custom built?
Do you have a motorcycle endorsement on your driver's license?
How many years of experience do you have driving a motorcycle?
Is your vehicle kept in a fully enclosed, locked structure?
Individual Health Information
SSN
*
Gender
*
Please Select
Male
Female
Are you applying for health insurance?
*
Please Select
Yes
No
Does your employer offer group health insurance?
*
Please Select
Yes
No
Do you currently have health insurance? please list if marketplace/individual/group
*
Please Select
Yes
No
Place of Employment
*
Pay Frequency?
*
Please Select
Hourly
Salary Monthly
Salary Annual
Payroll amount? (hourly pay rate/salary pay)
*
Are you a U.S. Citizen?
*
Please Select
Yes
No
Are you currently pregnant?
*
Please Select
Yes
No
Have you, in the past five years, used Tobacco or Nicotine products in any form?
*
Please Select
Yes
No
DEPENDENT'S
*
Any other form of income?
*
Please Select
Yes
No
Amount of additional Income
*
Life Quote Form
Gender
*
Please Select
Male
Female
Height
*
Weight
*
Are you a U.S. Citizen?
*
Please Select
Yes
No
Please list the names of the Beneficiary(ies) you would like AND Their Date of Birth
Have you, in the past five years, used Tobacco or Nicotine products in any form (e.g. cigarettes, pipes,cigars, snuff, chewing tobacco or nicotine delivery device such as gum or patch, etc.)?
*
Please Select
Yes
No
Have you, in the past ten years, had your driver's license suspended, revoked, pled guilty to, or beenconvicted of reckless driving, or driving under the influence (DUI/DWI)?
*
Please Select
Yes
No
Have you, in the past five years, pled guilty to or had any other driving conviction(s) (e.g. speeding, cellphone/texting, accident, etc.)?
*
Please Select
Yes
No
Have you, in the past ten years, pled guilty to or been convicted of a felony or misdemeanor, or are such charges pending against you, or are you currently on parole or probation?
*
Please Select
Yes
No
Have you had an application for life, accident, or health insurance, or reinstatement of a policy, declined,postponed, cancelled, or issued other than as applied for?
*
Please Select
Yes
No
Are you a member of the military, military reserve or National Guard (active or inactive) or do you have awritten agreement to become a member at the future date?
*
Please Select
Yes
No
Within the next two years, do you plan to travel, work or reside outside the US?
*
Please Select
Yes
No
Have you, in the past two years, flown as a student pilot, pilot or crew member (or do you plan to within the next two years)?
*
Please Select
Yes
No
Have you, in the past two years, or do you plan to in the next two years, take part in hang gliding, parasailing, para kiting, parachuting, skydiving, ultralight, soaring, ballooning, bungee jumping, rock or mountain climbing, organized racing by automobile, motorcycle, powerboat or snowmobile, or underwater diving?*
*
Please Select
Yes
No
Have you, in the past five years, been treated for, been hospitalized for, or been diagnosed by a member of the medical profession as having Human Immunodeficiency Virus (HIV) antibodies or antigens or AcquiredImmune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC) or any other immune deficiency disorder, or have you tested positive for HIV antibodies or antigens?
*
Please Select
Yes
No
Have you ever used or been treated for the use amphetamines, barbiturates, cocaine, marijuana, opiates, hallucinogens or any other illegal drugs or have you been treated by or consulted a member of the medical profession for abuse of prescription drugs?
*
Please Select
Yes
No
Have you ever been advised by a medical profession to reduce or stop drinking alcohol, or received treatment of any kind for the use of alcohol?
*
Please Select
Yes
No
Do you currently drink alcoholic beverages?
*
Please Select
Yes
No
Have you, in the past five years, been disabled, received disability income benefits, or been unable to to work or perform and carry out your normal daily functions for any reason other than maternity leave or recovery from minor surgery?
*
Please Select
Yes
No
Have you, in the past five years, been diagnosed by a member of the medical profession for any other illness, disease, or injury, not included in your answers to any of the preceding questions?
*
Please Select
Yes
No
Have you, in the past five years, been admitted or advised to be admitted to any hospital or health care facility; or undergone or been advices to have surgery, biopsies, treatment or medical test that are not included in your answers to any of the preceding questions?
*
Please Select
Yes
No
Have you ever attempted suicide?
*
Please Select
Yes
No
List any medications (include the name, dosage, frequency, how long you were on the medication and it's purpose):
Name of Current Employer
*
Length of Employment W/Company
*
Yearly Income (Gross)
*
Have you filed for Bankruptcy in the past seven years?
*
Please Select
Yes
No
Do you have a primary health care physician?*
*
Please Select
Yes
No
If Yes what is their name and address?
What was the date of your last visit?
What was your last visit for?
Have you lost more than 15 pounds over the past 12 months?
*
Please Select
Yes
No
Do you have any congenial or birth disorders including blindness, deafness, missing limb(s), heart defect,Down's Syndrome, Autism or any other congenital disorder?
*
Please Select
Yes
No
Have you, in the past five years, consulted with, been diagnosed or treated by a member of the medical profession or hospitalized, or taken medication for High Blood Pressure or high cholesterol/ hyperlipidemia?
*
Please Select
Yes
No
Have you, in the past five years, consulted with, been diagnosed or treated by a member of the medical profession or hospitalized, or taken medication for Chest pain, angina, heartattack, heart murmur, stroke or transientischemic attack/ministroke (TIA), irregularheart beat/rhythm, othercirculatory or heartdisorder or coronaryartery/heartdisease/atherosclerosis?
*
Please Select
Yes
No
Have you, in the past five years, consulted with, been diagnosed or treated by a member of the medical profession or hospitalized, or taken medication for Cancer, tumor, mass, skin cancer includingmelanoma, leukemia, lymphoma, colon polyp, or any malignant orbenign growth?
*
Please Select
Yes
No
Have you, in the past five years, consulted with, been diagnosed or treated by a member of the medical profession or hospitalized, or taken medication for Diabetes, impaired glucose tolerance (pre-diabetes), gestational diabetes, anemia or other blood disorder(excluding HIV), or disease or disorder of the thyroid, pituitary or adrenal glands?
*
Please Select
Yes
No
Have you, in the past five years, consulted with, been diagnosed or treated by a member of the medical profession or hospitalized, or taken medication for Depression, anxiety, stress, eating disorder(anorexia or bulimia), post-traumatic stress, attention deficit/attention deficit hyperactivity, bipolar or other psychiatric or mental health disorder?
*
Please Select
Yes
No
Have you, in the past five years, consulted with, been diagnosed or treated by a member of the medical profession or hospitalized, or taken medication for Seizures, paralysis, multiple sclerosis, memory loss or other disease or disorder of the nervous system
*
Please Select
Yes
No
Have you, in the past five years, consulted with, been diagnosed or treated by a member of the medical profession or hospitalized, or taken medication Asthma, chronic obstructive pulmonary disease, emphysema, chronic bronchitis, sleep apnea or any other disease or disorder o fthe lungs or respiratory system
*
Please Select
Yes
No
Have you, in the past five years, consulted with, been diagnosed or treated by a member of the medical profession or hospitalized, or taken medication for Kidney, bladder, urinary, reproductive organ(other than contraceptive medication) or prostate disorder
*
Please Select
Yes
No
Have you, in the past five years, consulted with, been diagnosed or treated by a member of the medical profession or hospitalized, or taken medication for Arthritis, fibromyalgia, gout, back or joint pain or muscle disorder, orLupus
*
Please Select
Yes
No
Family History Parent 1
*
Please Select
Living
Deceased
Current age at death?
Cause of death
Medical Conditions
Age at Diagnosis
Family History Parent 2
*
Please Select
Living
Deceased
Current age at death?
Cause of death
Medical Conditions
Age at Diagnosis
Family History: How many siblings? Are they living or deceased and any known medical conditions? Please list all below. Note if deceased please list cause of death and age at death.
What agent did you speak to about life coverage?
*
If you had an ideal budget to pay for life insurance, what would your monthly budget be?
$100/month
$200/month
$300/month
$400/month
Please upload current declarations page if available
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