Personal Lines Quote Form

How did you hear about us?*

What type of insurance quote are you requesting?

Name*

First NameLast Name

Date of Birth*

Date

Marital Status

Occupation (If Retired what occupation did you retire from?)

Email*

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Do we have permission to communicate via text with you at this number?*

YesNo

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is Mailing Address the same as the physical address?

Yes

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Secondary Insured

First NameLast Name

Secondary Insured's Date of Birth

Date

Desired Coverage Start Date*

Date

Is this home a new purchase?*

What is your home usage type?*

What year was your home built?

What is the square footage of your home?

How many stories is your home?

What year is your roof?

Roof Material

Plumbing Type

Wall Type

What type of flooring do you have in your house? If multiple, please give an estimate on % of each kind.

Do you have the following:*

Rows	Yes	No
Monitored Central Burglar Alarm
Monitored Central Fire Alarm
A Fire Hydrant outside within 1000 Feet of your home
Do you live in a gated community?
Do you have a fire place?
Have you filed for bankruptcy, Foreclosure, Repossession or Short Sale in the past 5 years?
Have you had your home insurance canceled, non-renewed or denied coverage?
Is the property located on more than 5 acres?
Is the home built OVER water?
Has the property had any sink hole activity?
Are there any dogs with bite history?

Drivers License Number

What were your prior liability limits on your last auto policy? *

Example 100/300/100 or 250/500/250 etc

Do you want Comprehensive Coverage on your vehicles?*

YesNo

Do you want Collision Coverage on your vehicles?*

YesNo

Do you want Towing?*

YesNo

Do you want rental coverage?*

YesNo

Do you want glass coverage?*

YesNo

How old were you when you got your first drivers license?*

How Many Vehicles do you own?*

How many drivers are in the household?*

What is the year, make & model of EACH Vehicle you would like insured?*

If you have more than just the 2 drivers above please list EACH driver's Full name, Date of Birth, Driver's License State, Drivers License Number, Expiration Date & Issued Date.

Please note quote will not be completed without all of this information. Please make sure if you have teenagers that this is included for them as well.

Is this home a new purchase?*

How is the home occupied?*

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?*

Roof Material *

Plumbing Type*

Monitored Central Burglar Alarm*

YesNo

If your home on a permanent foundation?*

YesNo

Monitored Central Fire Alarm

YesNo

Do you have any attached structures? (Add details in the notes section)*

YesNo

Do you have any detached structures? (Add details in the notes section)*

YesNo

Is your home on your own private property or in a park?*

My PropertyPark Community

A Fire Hydrant outside within 1000 Feet of your home*

YesNo

Do you live in a gated community?*

YesNo

Do you have a wood burning stove?*

YesNo

Have you filed for bankruptcy, Foreclosure, Repossession or Short Sale in the past 5 years?*

YesNo

Have you had your home insurance canceled, non-renewed or denied coverage?*

YesNo

Are there any dogs with bite history?*

YesNo

What type of flooring do you have in your house? If multiple, please give an estimate on % of each kind.*

Who is your current insurance carrier?*

Home Type*

What is the square footage of your home? *

How many stories is your home?*

Do you live in a gated community?

YesNo

Do you have a fire place?

YesNo

Have you filed for bankruptcy, Foreclosure, Repossession or Short Sale in the past 5 years?

YesNo

Are there any dogs with bite history?

YesNo

Do you have a pool?

YesNo

Who is your current insurance carrier?

Vin#*

Year

Make

Model

Value

Length

Weight

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?

HIN

Year

Make

Model

Motor Info

Horsepower

Length

Value

Motor Style

InboardOutboardOther

Coverages Requested?

Would you like environmental coverage?

Trailer Information

Length of time boat is in the water

Years of experience driving boats?

How many years have you owned your boat?

Hull material

Fuel type

Power type

Max speed

Number of engines

Coastal or inland water use?

Vin #

Year

Make

Model

How many CCs?

Value

Requested coverages

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?

How Many People In Your Household Are Applying For Health Coverage?

Type Legal First and Last Name and Full Date of Birth of Each Person Applying for Health Coverage Below.

Example; John Smith 01/01/2001

What are you looking for in a health plan (low price, coverage for larger health expenses, certain medications or doctors, see the doctor often or rarely, etc.)

Are any adults applying for health insurance tobacco users?

Who is your current insurance carrier?

Gender*

Place of Birth (City & State)*

SSN*

Height*

Weight*

U.S. Driver's License #*

State of Issue*

Expiration Date

Date

Are you a U.S. Citizen?*

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.)?*

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)?*

Have you, in the past five years, pled guilty to or had any other driving conviction(s) (e.g. speeding, cellphone/texting, accident, etc.)?*

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?*

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?*

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?*

Within the next two years, do you plan to travel, work or reside outside the US?*

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)?*

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?*

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?**

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?*

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?*

Do you currently drink alcoholic beverages?*

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?*

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?*

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?*

Have you ever attempted suicide?*

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?*

Do you have a primary health care physician?**

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?*

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?*

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? *

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? *

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? *

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? *

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 Disorder of the liver, pancreas, digestive system or spleen including hepatitis, ulcers, intestinal bleeding, cirrhosis, fatty liver, or weight loss surgery? *

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? *

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*

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*

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*

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 *

Family History Parent 1*

Current age at death?

Cause of death

Medical Conditions

Age at Diagnosis

Family History Parent 2*

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.

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

Any additional notes you would like us to know?

Personal Lines Quote Form

Home Information

Auto Information

Mobile/Manufactured Home Information

Renters Information

Motorhome/Travel Trailer Information

Boat Information

ATV/Motorcycle Information

Individual Health Information

Life Quote Form