Home Quote - Amanda Campbell Agency

Home Quote Form

Phone: (877) 794-2730
How did you hear about us?
Please provide more detail?
Contact Information
Who is completing this form?
If you are helping the homeowner, please tell us who you are:
Which Team Member?
Name

First NameLast Name
Gender
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?
By providing a mobile phone number, you confirm that you are the subscriber or authorized user of that number and consent to receive text messages from Amanda Campbell Agency regarding quotes, policies, and account-related information. Message frequency may vary. Message and data rates may apply. Reply STOP to opt out.
By providing a mobile phone number, you confirm that you are the subscriber or authorized user of that number and consent to receive text messages from Amanda Campbell Agency regarding quotes, policies, and account-related information. Message frequency may vary. Message and data rates may apply. Reply STOP to opt out.
Email
example@example.com
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Occupation (If Retired what occupation did you retire from?)
Marital Status
Would you like to add a secondary insured?
Secondary Insured

First NameLast Name
Secondary Insured Gender
Secondary Insured's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Secondary Insured Occupation (If Retired what occupation did you retire from?)
Relationship to Primary Insured
Property Information
Are you just purchasing or moving into this home?
What is your expected close or move-in date?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Effective Date (Desired Coverage Start Date)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Property Address

Street Address

Street Address Line 2

CityState

Zip Code
Have you lived at this property for 4 years or more?
Previous address:

Street Address

Street Address Line 2

CityState

Zip Code
Is your mailing address different from the property address?
Mailing address:

Street Address

Street Address Line 2

CityState

Zip Code
Home Details
Policy Type
Structure Type
If your Structure type is Other, please explain:
Home Use?
How many months of the year is the home occupied?:
Personal Property Coverage:
How much coverage would you like for your personal belongings? This includes items such as furniture, clothing, electronics, appliances, yard equipment and other belongings.
Mobile/Manufactured Home Details

MHO or MDP
Width of Mobile Home (feet)
Example: 28
Length of Mobile Home (feet)
Example: 76
Manufacturer/ Make of the Mobile Home
Model of the Mobile Home
Serial Number/HUD label Number
Mobile Home Location
Park Name or Subdivision Name
Do you own or lease the land where the mobile home is located?
Condo Details

HO-6
Condominium/Community Name
Who is responsible for roof replacement or repair?
Number of Stories in the Building
Number of Units in the Building
Unit location Within the Building
Floor Where Your Unit is Located
Is the Building equipped with an automatic fire sprinkler system?
What Personal Liability Limit does the condo association require?
Do you have a copy of the condo association's master insurance policy or certificate of insurance?
Renters Details

HO-4
How many roommates do you have who are not related to you?
Enter 0 if none
Does your landlord require a specific personal liability limit?
What Personal Liability Limit is Required?
Physical Property Details
Year Built
New Construction Details (Builder, Model, Link)
Square Feet
Stories
Water Heater year
Water Heater Location
Roof year
Roof Material
Roof Shape
Plumbing Type
Exterior Wall Build
Exterior Wall Finish
Foundation Type
Property & Liability Details

Please answer a few quick questions that may affect eligibility or discounts
Pool Type
Pool Safety:
Are there any detached structures on the property?
Describe the detached structures (type, size, approximate value, and use)
e.g. Shed, barn, detached garage, workshop, guest house, stable
Claims in the last 5 years?
Claim Details (date, type of loss & amount paid)
Number of Claims
Has an insurance company cancelled or non-renewed your policy in the past 3 years?
Explain:
Is there a swimming pool on the property?
Swimming Pool Type:
Do you have any animals or dogs that would be considered high-risk by insurance carriers?
List the breeds or details of the animals
Is any part of the home used for business purposes?
Describe the business activity
Does any insured qualify for the following? (check all that apply):
Current Home Insurance
Why are you shopping for insurance?
Please Explain:
Do you currently have insurance?
Who was your current/previous carrier?
When does your current/previous policy expire?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Other:
Discounts, Credits & Affiliations

Select all that apply
Secured Community
Community/Neighborhood Name
Security Features
Community
Public Service
Memberships & Affiliations
Would you like an Auto Insurance Quote to see if bundling your policies can save you money?
Auto Insurance
Current Auto Insurance
What is your current auto insurance status?
A lapse means any period when you did not have active auto insurance coverage.
Current Auto Insurance Carrier
Current Auto Policy Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
When did your previous auto insurance coverage end?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Auto Policy Coverages

The coverages below apply to the entire auto policy, not to a specific vehicle. If you're unsure what to choose, select “Help Me Decide.
How would you like us to quote your auto coverage?
Desired Liability Limits (BI / PD)
Limits are shown in thousands. For example, 100/300/100 means $100,000 Bodily Injury per person, $300,000 Bodily Injury per accident, and $100,000 Property Damage per accident.
Personal Injury Protection (PIP)
Florida auto policies include Personal Injury Protection (PIP), which helps pay covered medical expenses and lost wages after an auto accident, regardless of who was at fault. We will include PIP in your quote and review available options with you.
Desired Medical Payments Coverage
Helps pay covered medical expenses for you and your passengers after an auto accident, regardless of fault, and may help with expenses not fully covered by PIP.
Desired Uninsured/Underinsured Motorist (UM)
Helps cover injuries caused by a driver with no Bodily Injury coverage or not enough coverage. UM does not cover damage to your vehicle.
How many people age 14 or older live in your home?
Include yourself and all household members age 14 or older, whether licensed or not.
Household Member 1

Primary Insured
Primary Insured
Primary's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
HM1 - Gender
HM1 - Education Level
HM1 - Employment Status
HM1 - Driver's License Status
HM1 - Driver's License Number
HM1 - Driver's License State
HM1 - How should the member be listed on the auto policy?
HM1 - Why should this member be excluded from the policy?
Household Member 2
HM2 - Name

First NameLast Name
HM2 - Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
HM2 - Gender
HM2 - Marital Status
HM2 - Relationship to Primary Insured
HM2 - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
HM2 - Email
example@example.com
HM2 - Employment Status
HM2 - Education Level
HM2 - Driver's License Status
HM2 - Driver's License Number
HM2 - Driver's License State
HM2 - How should the member be listed on the auto policy?
HM2 - Why should this member be excluded from the policy?
Household Member 3
HM3 - Name

First NameLast Name
HM3 - Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
HM3 - Gender
HM3 - Marital Status
HM3 - Relationship to Primary Insured
HM3 - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
HM3 - Email
example@example.com
HM3 - Employment Status
HM3 - Education Level
HM3 - Driver's License Status
HM3 - Driver's License Number
HM3 - Driver's License State
HM3 - How should the member be listed on the auto policy?
HM3 - Why should this member be excluded from the policy?
Household Member 4
HM4 - Name

First NameLast Name
HM4 - Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
HM4 - Gender
HM4 - Marital Status
HM4 - Relationship to Primary Insured
HM4 - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
HM4 - Email
example@example.com
HM4 - Employment Status
HM4 - Education Level
HM4 - Driver's License Status
HM4 - Driver's License Number
HM4 - Driver's License State
HM4 - How should the member be listed on the auto policy?
HM4 - Why should this member be excluded from the policy?
Household Member 5
HM5 - Name

First NameLast Name
HM5 - Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
HM5 - Gender
HM5 - Marital Status
HM5 - Relationship to Primary Insured
HM5 - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
HM5 - Email
example@example.com
HM5 - Employment Status
HM5 - Education Level
HM5 - Driver's License Status
HM5 - Driver's License Number
HM5 - Driver's License State
HM5 - How should the member be listed on the auto policy?
HM5 - Why should this member be excluded from the policy?
Household Member 6
HM6 - Name

First NameLast Name
HM6 - Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
HM6 - Gender
HM6 - Marital Status
HM6 - Relationship to Primary Insured
HM6 - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
HM6 - Email
example@example.com
HM6 - Employment Status
HM6 - Education Level
HM6 - Driver's License Status
HM6 - Driver's License Number
HM6 - Driver's License State
HM6 - How should the member be listed on the auto policy?
HM6 - Why should this member be excluded from the policy?
Vehicle Information
How many vehicles would you like included in the quote?
Vehicle 1 Information
V1 - Year
V1 - Make
V1 - Model
V1- Year Purchased
V1 - Vehicle Identification Number (VIN)
Most VINs are 17 characters and do not contain the letters I, O, or Q.
V1 - Ownership
V1 - Primary Use
V1 - One-Way Commute Miles
Enter the approximate number of miles from home to work/ school.
V1 - Approximate Annual Miles
V1 - Primary Driver
Enter the name of the person who drives this vehicle most often.
Vehicle 1 Coverages
V1 - Physical Damage Coverage
Choose whether you want coverage for damage to this vehicle or liability coverage only.
V1 - Comprehensive Deductible
Applies to damage from things like theft, weather, fire, or hitting an animal.
V1 - Collision Deductible
Applies to damage to your vehicle from a collision with another vehicle or object.
V1 - Rental Reimbursement
Helps pay for a rental vehicle while your vehicle is being repaired after a covered loss.
V1 - Roadside Assistance
Provides assistance for services such as towing, a dead battery, flat tire, or lockout.
Vehicle 2 Information
V2 - Year
V2 - Make
V2 - Model
V2- Year Purchased
V2 - Vehicle Identification Number (VIN)
Most VINs are 17 characters and do not contain the letters I, O, or Q.
V2 - Ownership
V2 - Primary Use
V2 - One-Way Commute Miles
Enter the approximate number of miles from home to work/ school.
V2 - Approximate Annual Miles
V2 - Primary Driver
Enter the name of the person who drives this vehicle most often.
Vehicle 2 Coverages
V2 - Physical Damage Coverage
Choose whether you want coverage for damage to this vehicle or liability coverage only.
V2 - Comprehensive Deductible
Applies to damage from things like theft, weather, fire, or hitting an animal.
V2 - Collision Deductible
Applies to damage to your vehicle from a collision with another vehicle or object.
V2 - Rental Reimbursement
Helps pay for a rental vehicle while your vehicle is being repaired after a covered loss.
V2 - Roadside Assistance
Provides assistance for services such as towing, a dead battery, flat tire, or lockout.
Vehicle 3 Information
V3 - Year
V3 - Make
V3 - Model
V3- Year Purchased
V3 - Vehicle Identification Number (VIN)
Most VINs are 17 characters and do not contain the letters I, O, or Q.
V3 - Ownership
V3 - Primary Use
V3 - One-Way Commute Miles
Enter the approximate number of miles from home to work/ school.
V3 - Approximate Annual Miles
V3 - Primary Driver
Enter the name of the person who drives this vehicle most often.
Vehicle 3 Coverages
V3 - Physical Damage Coverage
Choose whether you want coverage for damage to this vehicle or liability coverage only.
V3 - Comprehensive Deductible
Applies to damage from things like theft, weather, fire, or hitting an animal.
V3 - Collision Deductible
Applies to damage to your vehicle from a collision with another vehicle or object.
V3 - Rental Reimbursement
Helps pay for a rental vehicle while your vehicle is being repaired after a covered loss.
V3 - Roadside Assistance
Provides assistance for services such as towing, a dead battery, flat tire, or lockout.
Vehicle 4 Information
V4 - Year
V4 - Make
V4 - Model
V4- Year Purchased
V4 - Vehicle Identification Number (VIN)
Most VINs are 17 characters and do not contain the letters I, O, or Q.
V4 - Ownership
V4 - Primary Use
V4 - One-Way Commute Miles
Enter the approximate number of miles from home to work/ school.
V4 - Approximate Annual Miles
V4 - Primary Driver
Enter the name of the person who drives this vehicle most often.
Vehicle 4 Coverages
V4 - Physical Damage Coverage
Choose whether you want coverage for damage to this vehicle or liability coverage only.
V4 - Comprehensive Deductible
Applies to damage from things like theft, weather, fire, or hitting an animal.
V4 - Collision Deductible
Applies to damage to your vehicle from a collision with another vehicle or object.
V4 - Rental Reimbursement
Helps pay for a rental vehicle while your vehicle is being repaired after a covered loss.
V4 - Roadside Assistance
Provides assistance for services such as towing, a dead battery, flat tire, or lockout.
Vehicle 5 Information
V5 - Year
V5 - Make
V5 - Model
V5- Year Purchased
V5 - Vehicle Identification Number (VIN)
Most VINs are 17 characters and do not contain the letters I, O, or Q.
V5 - Ownership
V5 - Primary Use
V5 - One-Way Commute Miles
Enter the approximate number of miles from home to work/ school.
V5 - Approximate Annual Miles
V5 - Primary Driver
Enter the name of the person who drives this vehicle most often.
Vehicle 5 Coverages
V5 - Physical Damage Coverage
Choose whether you want coverage for damage to this vehicle or liability coverage only.
V5 - Comprehensive Deductible
Applies to damage from things like theft, weather, fire, or hitting an animal.
V5 - Collision Deductible
Applies to damage to your vehicle from a collision with another vehicle or object.
V5 - Rental Reimbursement
Helps pay for a rental vehicle while your vehicle is being repaired after a covered loss.
V5 - Roadside Assistance
Provides assistance for services such as towing, a dead battery, flat tire, or lockout.
Vehicle 6 Information
V6 - Year
V6 - Make
V6 - Model
V6 - Year Purchased
V6 - Vehicle Identification Number (VIN)
Most VINs are 17 characters and do not contain the letters I, O, or Q.
V6 - Ownership
V6 - Primary Use
V6 - One-Way Commute Miles
Enter the approximate number of miles from home to work/ school.
V6 - Approximate Annual Miles
V6 - Primary Driver
Enter the name of the person who drives this vehicle most often.
Vehicle 6 Coverages
V6 - Physical Damage Coverage
Choose whether you want coverage for damage to this vehicle or liability coverage only.
V6 - Comprehensive Deductible
Applies to damage from things like theft, weather, fire, or hitting an animal.
V6 - Collision Deductible
Applies to damage to your vehicle from a collision with another vehicle or object.
V6 - Rental Reimbursement
Helps pay for a rental vehicle while your vehicle is being repaired after a covered loss.
V6 - Roadside Assistance
Provides assistance for services such as towing, a dead battery, flat tire, or lockout.
Driver History
Has any household member had an accident, claim, ticket or moving violation in the past 5 years?
Include incidents for all household members listed above, even if they no longer drive.
Please provide details for each incident
Include the household member's name, approximate date, type of incident, and a brief description.
Does any household member require an SR-22 or FR-44 filing?
An SR-22 or FR-44 is a filing that may be required by the state after certain driving violations. If you are required to have one, you would typically have been notified by the state or court.
Who requires the filing?
Filing Case Number
Would you be interested in a driving-monitoring program if it could help lower your auto insurance premium?
Some carriers offer discounts for using a mobile app or device that monitors driving habits.
Any additional notes you would like us to know?
Upload Supporting Documents

Upload any documents that may help us prepare your quote, such as current insurance declarations, inspection reports, condo association insurance documents, or other relevant insurance/property documents
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Insurance Score Disclosure:

To provide you with an accurate insurance quote, our carrier partners may review your credit report and use a credit-based insurance score. This score is derived from information in your credit report and may affect eligibility and pricing.

By submitting this form, you authorize our agency and affiliated carriers to obtain and use this information for quoting purposes.

Submitting this form does not bind coverage. Coverage is not active until confirmed in writing by our agency.

If you have questions about how credit-based insurance scores are used, please let us know — we’re happy to help.
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Home Quote Form

Contact Information

Property Information

Home Details

Mobile/Manufactured Home Details

Condo Details

Renters Details

Physical Property Details

Property & Liability Details

Current Home Insurance

Discounts, Credits & Affiliations

Auto Insurance

Current Auto Insurance

Auto Policy Coverages

Household Member 1

Household Member 2

Household Member 3

Household Member 4

Household Member 5

Household Member 6

Vehicle Information

Vehicle 1 Information

Vehicle 1 Coverages

Vehicle 2 Information

Vehicle 2 Coverages

Vehicle 3 Information

Vehicle 3 Coverages

Vehicle 4 Information

Vehicle 4 Coverages

Vehicle 5 Information

Vehicle 5 Coverages

Vehicle 6 Information

Vehicle 6 Coverages

Driver History