Auto Quote Information Form

Auto Quote Information Form

Please fill the form as completely as possible for better assistance. The email box that this form is submitted to is monitored continuously and someone will be in touch with you very shortly once the form is submitted. All Data is encrypted. Landsman Insurance Services, LLC. NPN: 21500715 - 1-833-208-0034 NOTICE: ANY PERSON WHO, KNOWINGLY OR WITH INTENT TO DEFRAUD OR TO FACILITATE A FRAUD AGAINST ANY INSURANCE COMPANY OR OTHER PERSON, SUBMITS AN APPLICATION OR FILES A CLAIM FOR INSURANCE CONTAINING FALSE, DECEPTIVE OR MISLEADING INFORMATION MAY BE GUILTY OF INSURANCE FRAUD.
Primary Applicant*

First NameLast Name
Marital Status - Primary Applicant*

MarriedDivorcedSingleWidow / Widower
Primary Applicant Employment Status (Please Check all that apply)*

Household Manager/stay-at-home duties (full-time)Retired (not employed)Not currently employedFull time student (not employed or part-time employed)Agriculture/Forestry/FishingArt/ Design/MediaBanking/Finance/Real EstateBusiness/Sales/OfficeConstruction / Energy / MiningEducation/ LibraryEngineer/Architect/Science/MathFood Service / Hotel ServicesGovernment/MilitaryInformation TechnologyInsuranceLegal/Law Enforcement/SecurityMedical/Social Services/ReligionPersonal Care/ServiceProduction / ManufacturingRepair / Maintenance / GroundsSports/RecreationTravel / Transportation / Storage
Driver 2

First NameLast Name
Marital Status - Driver 2

MarriedDivorcedSingleWidow / Widower
Driver 2 Employment Status (Please Check all that apply)

Household Manager/stay-at-home duties (full-time)Retired (not employed)Not currently employedFull time student (not employed or part-time employed)Agriculture/Forestry/FishingArt/ Design/MediaBanking/Finance/Real EstateBusiness/Sales/OfficeConstruction / Energy / MiningEducation/ LibraryEngineer/Architect/Science/MathFood Service / Hotel ServicesGovernment/MilitaryInformation TechnologyInsuranceLegal/Law Enforcement/SecurityMedical/Social Services/ReligionPersonal Care/ServiceProduction / ManufacturingRepair / Maintenance / GroundsSports/RecreationTravel / Transportation / Storage
Driver 3

First NameLast Name
Marital Status - Driver 3

MarriedDivorcedSingleWidow / Widower
Driver 3 Employment Status (Please Check all that apply)

Household Manager/stay-at-home duties (full-time)Retired (not employed)Not currently employedFull time student (not employed or part-time employed)Agriculture/Forestry/FishingArt/ Design/MediaBanking/Finance/Real EstateBusiness/Sales/OfficeConstruction / Energy / MiningEducation/ LibraryEngineer/Architect/Science/MathFood Service / Hotel ServicesGovernment/MilitaryInformation TechnologyInsuranceLegal/Law Enforcement/SecurityMedical/Social Services/ReligionPersonal Care/ServiceProduction / ManufacturingRepair / Maintenance / GroundsSports/RecreationTravel / Transportation / Storage
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years at this address*
Does the Primary Applicant?*

Own the homeRentLive with family
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth - Primary Policyholder*

MonthDayYear
Date
Date of Birth - Driver 2

MonthDayYear
Date
Date of Birth - Driver 3

MonthDayYear
Date
License State - Primary Policyholder*
License # - Primary Policyholder*
License Expiration Date - Primary Policyholder*

MonthDayYear
Date
Driver 1 - Highest Level of Education*

No high school diploma or GEDHigh school diploma or GEDVocational / trade school degree or military trainingCompleted some collegeCurrently in collegeGraduate work or graduate degree
# of Years Licensed - Primary Policyholder*
Primary Policyholder License Expiration Date*

MonthDayYear
Date
License # & State - Driver 2
# of Years Licensed - Driver 2
Driver 2 - Highest Level of Education

No high school diploma or GEDHigh school diploma or GEDVocational / trade school degree or military trainingCompleted some collegeCurrently in collegeGraduate work or graduate degree
Driver 2 License Expiration Date

MonthDayYear
Date
License # & State - Driver 3
# of Years Licensed - Driver 3
Driver 3 - Highest Level of Education

No high school diploma or GEDHigh school diploma or GEDVocational / trade school degree or military trainingCompleted some collegeCurrently in collegeGraduate work or graduate degree
Driver 3 License Expiration Date

MonthDayYear
Date
Do any drivers drive for an app like Uber or Lyft or Door Dash, etc?*

YesNo
If Yes, which driver?

Driver 1Driver 2Driver 3
If Yes, which App?
Have any drivers had any claims in the past 3 years?*

YesNo
If Yes, which driver?

Driver 1Driver 2Driver 3
If yes, which vehicle was involved in the claim?

Vehicle 1Vehicle 2Vehicle 3
Have any drivers had any moving violations the past 3 years?*

YesNo
If Yes, which driver?

Driver 1Driver 2Driver 3
If yes, please list dates and the type of citation for each driver.
Are you currently insured?*
Current Insurance Carrier?*
Existing Insurance Policy Number*
Current Premium
Please supply a copy of your current policy. Please upload so that we can ensure we are matching or enhancing your current coverage.

Cancelof
Number of Years Uninterrupted Insurance Cover (Required to Quote). If more than 5, please enter "more than 5".*
Make of Vehicle 1*
Model of Vehicle 1*
Year of Vehicle 1*
VIN # - Vehicle 1*
Estimated # of miles driven per year? - Vehicle 1*
Is Vehicle 1 Financed?*

YesNoLeased
Outstanding Amount Owed on Vehicle 1
Name of Lienholder on Vehicle 1
Make of Vehicle 2
Model of Vehicle 2
Year of Vehicle 2
VIN # - Vehicle 2
Estimated # of miles driven per year? - Vehicle 2
Is Vehicle 2 Financed?

YesNoLeased
Outstanding Amount Owed on Vehicle 2
Make of Vehicle 3
Model of Vehicle 3
Year of Vehicle 3
Vin# of Vehicle 3
Estimated # of miles driven per year? - Vehicle 3
Is Vehicle 3 Financed?

YesNoLeased
Outstanding Amount Owed on Vehicle 3
Should be Empty: