• Legacy Partners Insurance – Personal Insurance Application

    Answer short questions and only fill the sections for the coverages you select; you can upload your current declarations pages at the end.

  • Contact

  • Format: (000) 000-0000.
  • Preferred contact method*
  • Is this application for a home you are purchasing (not closed yet)?*
  • Expected closing date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Moved in
     - -
    2 digit month, 2 digit day, 4 digit year
  • Moved out
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you need to add another previous address to cover the last 5 years?
  • Moved in
     - -
    2 digit month, 2 digit day, 4 digit year
  • Moved out
     - -
    2 digit month, 2 digit day, 4 digit year
  • Mailing address same as home?*
  • Date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Spouse / partner date of birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • What coverages would you like quoted?*
  • Desired effective date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Home

  • Is the property to be insured the same as the home address?*
  • Swimming pool?*
  • Trampoline?*
  • Dogs?*
  • Monitored security or fire alarm?*
  • Date moved in / purchased*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Mortgage?*
  • Any home claims in the past 5 years?*
  • Home claims details

  • Auto

  • List everyone in the household who is licensed, including teens and students away at school.
  • Drivers*
  • Vehicles*
  • Accidents, tickets, or claims for any driver in the past 5 years?*
  • Incident Details

  • Umbrella

  • Umbrella limit requested*
  • Do you own any rental properties, watercraft, or recreational vehicles not listed elsewhere?*

  • Renters

  • Landlord / Rental Property

  • Rental Type*
  • Occupancy Status*

  • RV / Travel Trailer

  • Full-time Residence?*

  • Golf Cart / UTV

  • Power Type*
  • Street Legal / Registered?*

  • Boat

  • Motorcycle

  • Current Insurance

  • Do you currently have insurance?*
  • Current renewal / expiration date(s)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Any insurance cancelled or non-renewed in the past 3 years?*
  • What matters most in this quote?

  • Documents

  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof

  • Authorization

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: