Language
English (US)
Spanish (Latin America)
Français
Italiano
German (Germany)
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
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.
By clicking the subscribe & agree button, I expressly consent by electronic signature to receive communications via automatic telephone dialing system or by artificial/pre-recorded message, email, or by text message from this website or their agents at the telephone number above (even if my number is currently listed on any state, federal, local, or corporate Do Not Call list) including my wireless number if provided, for the purpose of receiving information on insurance products and services. Carrier message and data rates may apply. 10 messages/mo. Reply HELP for help. Reply STOP to opt out. I understand that my consent is not required as a condition of purchasing any goods or services and that I may revoke my consent at any time. I also acknowledge that I have read and agree to the Privacy Policy and Terms & Conditions. For help or additional info contact christian@christianslayton.com
*
Subscribe & Agree
Do Not Accept
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
Is this home a new purchase?
*
Please Select
Yes
No
What is your home usage type?
*
Please Select
Owner Occupied
Rented to Others
Owner Occupied part time and rented to others part time
Vacant
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
Please Select
Shingles
Metal
Tile
Other
Plumbing Type
Please Select
Copper
Galvanized
PEX
Polybutylene
PVC
Wall Type
Please Select
Masonry
Frame
Mixed Masonry-Frame
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:
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?
Auto Information
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?
Yes
No
Do you want Collision Coverage on your vehicles?
Yes
No
Do you want Towing?
Yes
No
Do you want rental coverage?
Yes
No
Do you want glass coverage?
Yes
No
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.
Mobile/Manufactured Home Information
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?
*
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.
*
Who is your current insurance carrier?
*
Renters Information
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
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?
How many years have you owned your boat?
Hull material
Fuel type
Power type
Max speed
Number of engines
Coastal or inland water use?
ATV/Motorcycle Information
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?
Individual Health Information
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?
Life Quote Form
Gender
*
Please Select
Male
Female
Place of Birth (City & State)
*
SSN
*
Height
*
Weight
*
U.S. Driver's License #
*
State of Issue
*
Expiration Date
/
Month
/
Day
Year
Date
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 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, 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 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 Disorder of the liver, pancreas, digestive system or spleen including hepatitis, ulcers, intestinal bleeding, cirrhosis, fatty liver, or weight loss surgery?
*
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.
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
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Any additional notes you would like us to know?
Submit
Should be Empty: