Personal lines Quote Sheet

* PLEASE FILL THIS FORM ONLY IF YOU CURRENTLY DON'T HAVE FARMERS INSURANCE. THIS IS A FREE, NO OBLIGATION INSURANCE QUOTE. Thank you for agreeing to fill out this form, it will help your friend/acquaintance quote and save you money in the process! It will be worth your time.
Who are you filling this form for (Agent or potential Agent)?*
If the Agent is not listed, please enter their name below:
Your Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell phone?*
Format: (000) 000-0000.
What is your email Address?*
example@example.com
Date of Birth?*

MonthDayYear
Date
Number of Vehicles?*
How many vehicles do you need insured on this policy?

Tell us about your car(s):*

Rows	MAKE/MODEL	Full coverage (F) or Liability (L)	$1,000 or $500 Deductible	Tow ? Y/N	$0 Glass coverage? Y/N	Rental car coverage? Y/N	Uber? Y/N	ANNUAL MILES DRIVEN (CA only)
CAR 1
CAR 2
CAR 3
CAR 4
CAR 5

Number of drivers in home including yourself?*
How many drivers do you need insured on this policy?

Tell us about the driver(s):*

Rows	FULL NAME	DATE OF BIRTH	CELL PHONE	GOOD STUDENT (<24 years with 3.0 GPA)? Y/N	Any tickets or accidents? Y/N
Driver 1
Driver 2
Driver 3
Driver 4
Driver 5

Which insurance company are you insured with?*
How much are they charging you?*
Do you have life insurance with your current company? We offer an 8% discount- ask about it! *
Military (Active or Retired)- 5%Business OwnerLife Insurance-3-8%BoatRV / Motorhome- 3-5%Motorcycle/ATV- 5%Pay in full- 5%Mature driver course - 10%EFT- 2%Water leak detection device- 6%Umbrella - 5%Other
FOR CALIFORNIA ONLY- What is your occupation for a discount (UP TO 15%)?
Do You Rent or Own Your Home? We will give you a 20% bundle discount!*
RENTER

Up to 20% discount for bundling!!
If you are a RENTER, what is the value of your personal property that you want to insure?
What insurance company carries your renters insurance?
How much are you being charged for your RENTERS insurance?
Current Term Premium (always 12 Months of coverage at a time)
HOMEOWNER

Up to 22% discount for bundling!!
IF YOU ARE HOMEOWNER, PLEASE ANSWER THE HOME QUESTIONS BELOW: What is your home style?
How Old Is Your Roof?
Either enter "X years old" or enter the year it was last replaced (fully)
1 car2 cars3 cars4 cars
1234 +
VinylAluminum/steelClapboardBrickBrick VeneerOther
1234+
PoolTrampolineDeck
What is your deck made of and how big is it?
If you have a pool, is it fenced?
YESNO
How much of it is finished (1-100%)?
Current Insurer - Enter NA if home is not insured
Home Insurance Company?
Current Insurer - Enter NA if home is not insured
How much are your being charged for your home insurance? *
Current Term Premium (always 12 Months of coverage at a time)
YESNO
How would you rate your current agent?*
Do you have any other insurance needs- business, lanlord, insure a cabin, umbrella, buy/sell agreements, annuity, investments etc? Please share what else you may be interested in.
Please Upload Any Insurance Documentation. The 'Declarations Page' will allow us to compare our quote to yours and make sure we don't miss anything.

Cancelof
Should be Empty:

* PLEASE FILL THIS FORM ONLY IF YOU CURRENTLY DON'T HAVE FARMERS INSURANCE. THIS IS A FREE, NO OBLIGATION INSURANCE QUOTE. Thank you for agreeing to fill out this form, it will help your friend/acquaintance quote and save you money in the process! It will be worth your time.

RENTER

HOMEOWNER