Get a Quote From Campisano Insurance!
Are you a current client of ours?
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Full Name
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First Name
Last Name
Email Address
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example@example.com
Phone Number
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Please enter a valid phone number.
What Kind Of Insurance Are You Looking For?
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Boat Insurance
Auto Insurance
Home Insurance
Business Insurance
For Faster Service, Boat, Auto, or Home Insurance we have an option to
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Submit your current policy documents (Quickest)
Schedule a call to go over everything (Easiest)
Fill Out Your Information and we will get back to you with a quote ASAP! (Best for those that do not have insurance currently)
For your boat insurance, what carrier are you currently with?
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Please Select
Markel Insurance
Travelers Insurance
Progressive Insurance
Chubb Insurance
Other
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Basic Insurance Quote Information
Please provide the following information to receive an insurance quote from us.
Full Name
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First Name
Last Name
Email Address
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example@example.com
Phone Number
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Please enter a valid phone number.
Home Address
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Street Address
Street Address Line 2
City
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Alabama
Alaska
Arizona
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Connecticut
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District of Columbia
Florida
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Michigan
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Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State Acronym
Zip Code
Is this also the Mailing Address?
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Yes
No
Mailing Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
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Month
-
Day
Year
Occupation
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What is your highest level of education?
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High School Diploma
General Educational Development (GED)
Bachelors Degree
Higher Education
Other
Marital Status
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Single
Married
Divorced
Widowed
Are there any other drivers/household residents?
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Yes
No
All Household Residents And/Or Drivers Other Than The Named Insured
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Boat Insurance Quote Information
Please provide the following information to receive a boat insurance quote from us.
Basic Boat Information
Boating Class?
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State Basic
USCG
USPS
LIC CAPTAIN
TON
Year
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Make
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Model
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Length (in feet)
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Motor
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I/O
I/B
O/B
# of Motors
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1
2
3
4
Motor Make
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Merc
Yamy
Volvo
Other
Fuel Type:
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Gas
Diesel
Horsepower
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Summer Mooring Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Address:
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Please Select
Ashore
Hydraulic Lift
Slip
Trailer
Is the summer mooring address the same as your winter storage address?
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Yes
No
Winter Storage Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type:
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Please Select
Ashore
Hydraulic Lift
Slip
Trailer
Extra Boat Info to Get You That Quote ASAP
Hull Insured Value Requested
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Date of Purchase
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Month
-
Day
Year
Date
Vessel Original Purchase Price
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Last Survey Date (if any)
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Navigation Territory:
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Please Select
Atlantic Coast and Inland Water Northeast
Atlantic Coast to North Carolina
Atlantic Coast from ME to FL
Atlantic Coast Florida waters Including Bahamas
Caribbean Waters
Do you have any Previous Claims in the last 5 years:
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Yes
No
Do you have a Trailer? (if any)
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Yes
No
Trailer Information
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Have you owned any vessels previously?
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Yes
No
Years of Boating Ownership Experience
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Prior Ins. Carrier: (N/A if none)
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Last Two owned vessels:
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Layup Dates if over 27 feet:
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Please Select
11/1-4/1
11/1-5/1
12/1-4/1
12/1-5/1
No Lay-Up
Other
Survey Upload (2 Years or Newer Survey)
Browse Files
Drag and drop files here
Choose a file
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Any other info on the boat you would like to share?
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Home Owners Insurance
Prior/Current Insurance Provider
*
Policy Expiry/Renewal Date
*
-
Month
-
Day
Year
Date
Upload your current Declaration Pages or your proof of insurance if you have any
*
Browse Files
Drag and drop files here
Choose a file
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Home Square Footage
*
Year Built
*
Is your home finished?
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Yes
No
What % Of Your Home is Finished?
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Does your home have any of the following things?
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Garage
Porch
Deck
Fireplace
Trampoline
Animals
In The Ground Pool
Above The Ground Pool
Solar
Fence
None
Do you have:
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Dog w/ bite history
Dog without bite history
Exotic Animals
None
What kind of breeds do you own?
*
Do you have any accidents/tickets/claims in the past 5 years?
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Yes
No
Please Describe Each Event
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Auto Insurance
Current/Previous Auto Insurance Company
*
When will your current auto policy expire/renew?
*
-
Month
-
Day
Year
Date
Upload your current Declaration Pages or your proof of insurance
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
List Of All Vehicles
*
Do you have any accidents/tickets/claims in the past 5 years?
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Yes
No
Please Describe Each Event
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Business Insurance Questionnaire
Business Name
*
Short Description of Business
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FEIN
*
Date of business creation
*
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Month
-
Day
Year
Date
Type of Business
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Nonprofit
Corporation
Partnership
Individual
LLC
Other
Understanding your businesses regular practices to understand what coverages you need
Does your business own or use any vehicles?
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Yes
No
Does your business have any property?
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Yes
No
Are you a healthcare provider?
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Yes
No
Do you have employees?
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Yes
No
Do clients pay you for your expertise, advice, or professional judgment? Especially where it could put them in harms way or cost them financially
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Yes
No
Does your business store customer info, credit card #'s, or personal data on computers?
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Yes
No
Do you currently have insurance for your company already?
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Yes
No
Current Insurance Carrier(s) Names:
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Current Policy Expiration Date
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-
Month
-
Day
Year
Date
Current Policy Retroactive Date
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-
Month
-
Day
Year
Date
Gross Annual Revenue ($)
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Gross Annual Payroll ($)
*
Number of employees
*
Desired Effective Date for New Policy
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-
Month
-
Day
Year
Date
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Other Policy Asks
Any other questions or information you would like to give:
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How do you like to make payments for your insurance? (There are usually discounts the more you pay up front.)
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All up front
Monthly
Submit
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