Byers Insurance Group
Please Complete as much information as possible.
Household Members Information
Named Insured 1
*
First Name
Last Name
Date of Birth
*
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January
February
March
April
May
June
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September
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November
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Month
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31
Day
Please select a year
2026
2025
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1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Driver's License Number
State
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Named Insured 2
First Name
Last Name
Date of Birth
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Driver's License Number
State
Phone Number
-
Area Code
Phone Number
E-mail
Additional Occupants
Name | Date of Birth | Driver's License Number & State
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Homeowners Information
Please complete as much as possible. If you're a renter, skip this page and complete the next page.
Current Insurance Carrier
How Long?
Round up to the nearest year
Policy Type
Please Select
Home Owner
Condo Owner
Manufactured Home Owner
Residence Use
Please Select
Primary
Secondary
Seasonal
Current/New Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Previous Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Coverage Amount
Deductible
Year Built
Bedrooms
Please Select
1
2
3
4
5
6
Bathrooms
Please Select
1
1.5
2
2.5
3
3.5
4
4.5
5
5.5
6
Stories
Please Select
1
1.5
2
2.5
3
Sewer Type
Please Select
Sewer
Septic
Sump Pump
None of the Above
Foundation Type
Please Select
Slab
Basement
Crawlspace
Post
Pier
Grade-Beam
None of the Above
Basement Finish %
Walk-Out?
Please Select
Yes
No
Construction Type
Please Select
Frame
Masonry
Log
Concrete
Adobe Block
Steel
None of the Above
Exterior Finish
Please Select
Brick
Earth
Vinyl
Aluminum
Steel
Cement
Masonite
Log
Wood
Stone
Stucco
None of the Above
Above-Ground Square Footage
Roofing Type
Please Select
Architectural Shingles
Standard 3-Tab Shingles
Built-Up Tar w/o Gravel
Built-Up Tar with Gravel
Clay Tile
Concrete Tile
Fiber Cement Tile
Foam
Metal
Rolled Composition
Rubber Membrane
Slate
Synthetic/Plastic Shingles
Sod/Eco
Wood Shakes/Shingles
Solar Shingles
None of the Above
Age
Pool
Please Select
In-Ground
Above Ground
None
Fenced
Heating System
Please Select
Central
Area
None
Fireplace
Please Select
None
Electric
Gas
Insert
Wood
None of the Above
Wood Stove?
Please Select
Yes
No
If Yes, Manufacturer & Serial Number
Garage Size
Please Select
None
Carport
1
1.5
2
2.5
3
3.5
4
4.5
5
Security System
Please Select
None
Burglar
Fire
Both
Pool?
Please Select
Yes
No
Pets & Breed
Claims In The Last 5 Years
Claim Type | Year of Claim
Other Structure on Premise 1
Please Select
Detached Garage
Guest House
Outdoor Pool
Outdoor In-Ground Spa
Pool House
Detached Greenhouse
Animal Shelter
Stable
Detached Solar Panel
Detached Wind Generator
Storage Shed Over 300 sq.ft.
Storage Shed At/Under 300 sq.ft.
Driveway & Walkway
Fence
Landscaping
Retaining Wall
Detached Carport
Detached Deck
Detached Patio
Detached Screened Enclosure
Detached Gazebo/Pergola
Outdoor Kitchen
Hoop Building
Permanent Boat Dock
Detached Antenna
Detached Satellite Dish
Basketball Court
Tennis Court
Landscape Fountain
Sign
Value
Other Structure on Premise 2
Please Select
Detached Garage
Guest House
Outdoor Pool
Outdoor In-Ground Spa
Pool House
Detached Greenhouse
Animal Shelter
Stable
Detached Solar Panel
Detached Wind Generator
Storage Shed Over 300 sq.ft.
Storage Shed At/Under 300 sq.ft.
Driveway & Walkway
Fence
Landscaping
Retaining Wall
Detached Carport
Detached Deck
Detached Patio
Detached Screened Enclosure
Detached Gazebo/Pergola
Outdoor Kitchen
Hoop Building
Permanent Boat Dock
Detached Antenna
Detached Satellite Dish
Basketball Court
Tennis Court
Landscape Fountain
Sign
Value
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Next
Renters Information
Please complete as much as possible.
Current Insurance Carrier
How Long?
Round up to the nearest year
Residence Type
Please Select
Single Family Dwelling
Duplex
Apartment Complex
Condo
Townhouse
Manufactured Home
Residence Use
Please Select
Primary
Secondary
Seasonal
Security System
Please Select
None
Burglary
Fire
Both
Fire Sprinkler System
Please Select
Yes
No
Heating System
Please Select
Central
Area
None
Heating Type
Please Select
Forced Air
Radiant
Heating Fuel
Please Select
Electric
Gas
Oil
Solid
Geothermal
None of the Above
Fireplace 1
Please Select
None
Electric
Gas
Insert
Wood
None of the Above
Fireplace 2
Please Select
None
Electric
Gas
Insert
Wood
None of the Above
Pets & Breed
Claims In The Last 5 Years
Claim Type | Year of Claim
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Autos Information
Please complete as much as possible.
Current Insurance Carrier
How Long?
Round up to the nearest year
Claims In The Last 5 Years
Claim Type | Year of Claim
Current Bodily Injury Limits
Please Select
None
$25,000/$50,000
$50,000/$100,000
$100,000/$300,000
$250,000/$500,000
$500,000/$500,000
$500,000/$1,000,000
$750,000/$750,000
$750,000/$1,000,000
$1,000,000/$1,000,000
Not Sure
None of the Above
Current Property Damage Limits
Please Select
None
$10,000
$25,000
$50,000
$100,000
$250,000
$300,000
$500,000
$1,000,000
Not Sure
None of the Above
Current Uninsured/Underinsured Limits
Please Select
None
$25,000/$50,000
$50,000/$100,000
$100,000/$300,000
$250,000/$500,000
$500,000/$500,000
$500,000/$1,000,000
$750,000/$750,000
$750,000/$1,000,000
$1,000,000/$1,000,000
Not Sure
None of the Above
Current Collision Deductible
Please Select
None
$0
$50
$100
$250
$500
$750
$1,000
$1,250
$1,500
$2,000
$2,500
$5,000
Not Sure
None of the Above
Current Comprehensive Deductible
Please Select
None
$0
$50
$100
$250
$500
$750
$1,000
$1,250
$1,500
$2,000
$2,500
$5,000
Not Sure
None of the Above
Current Roadside Service?
Please Select
Yes
No
Not Sure
Current Rental Car Coverage?
Please Select
Yes
No
Not Sure
Vehicle 1
Year | Make | Model | VIN# | Miles Drive Per Year | Lienholder Info
Vehicle 2
Year | Make | Model | VIN# | Miles Drive Per Year | Lienholder Info
Vehicle 3
Year | Make | Model | VIN# | Miles Drive Per Year | Lienholder Info
Vehicle 4
Year | Make | Model | VIN# | Miles Drive Per Year | Lienholder Info
Vehicle 5
Year | Make | Model | VIN# | Miles Drive Per Year | Lienholder Info
Vehicle 6
Year | Make | Model | VIN# | Miles Drive Per Year | Lienholder Info
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