Insurance Quote Request

Date & Time of Request
Contact Info
Name of Insured *

First Name Last Name
Phone Number *

Area Code Phone Number
Email *
example@example.com

Address (If purchasing home, put new address here) *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

How long have you lived at this address? *

Less than 1 year 1-3 years more than 3 years

Prior Address?

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Is your home address the same as your mailing? *

YES No

Mailing Address?

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Do you own your home?

Yes No Rent

Spouse
Name

First Name Last Name
Sex?

Male Female
Date of Birth

Month Day Year Date Picker Icon
Driver's License Number
Social Security Number
Occupation?
Highest Level of Education?

Less than Highschool Highschool Some College College Graduate

Are you interested in an Auto Insurance Quote? *

Yes No

History
Any Accidents, Violations or Claims in the last 5 years? *

Yes No
Please explain (ie.: at fault or not at fault) (include driver and dates if possible)
Be as accurate as possible, we WILL run the MVR before the policy is sold and any omissions could change the quoted price!

Policy Information
Is there a lienholder on the vehicle? *

Yes No
Name of Lienholder with address

Prior Insurance
Do you currently have auto insurance? *

Yes No
What Carrier?
What are your current Limits of Liability? (If known)

25/50/25 50/100/50 100/300/100 250/500/100
When does your current policy expire?

Month Day Year Date Picker Icon
If you would like to upload any documents; ie: prior policy information, photos of vehicle, add them below.
Upload File

Are you interested in insurance for your home & contents? *

YES NO

Home Insurance Quote Information
Is your home a mobile home or trailer? *

YES NO
Select which option best describes your situation. *

I do not own my home. I am a renter. I own my home and live in my home. I own my home, but rent it to others.

Residents Information
How many people live in the home? *
How many residents are children? *
Under the age of 18
Do you have any pets? *

YES NO
How many pets?
What type / breed?

Structure Information
The home is *

Brick Frame Block
How many square feet? *
How many stories? *
What year was the home built? *

What is/was the purchase date?
What was the purchase price of the home? *
Is there a mortgagee on the home? *

YES NO

Who is the mortgagee?

Name
Street Address
City	State
Zip Code	Country

Will the payments be escrowed?

YES NO
Escrowed is when the mortgagee company pays the premium.
The home is... *

Primary Seasonal Tenant Occupied
*Tenant occupied means you are the "landlord"
and rent out the home to someone else.

History
Is there a current insurance policy in place? *

YES NO
Current Insurance Company?
Current Amount of Insurance?
What is the effective date of current policy?

Month Day Year
Date Date Picker Icon
Has the policy been cancelled or non-renewed?

YES NO
What is the reason for cancellation or non-renewal?
Have you had any prior losses or claims? *

YES NO
Please describe prior losses/claims.
Include dates, cause, and amount paid for each.
If available, please upload prior policy information here.
When quoting a home, it is helpful to have photos of the exterior of the property. If available, you can upload a photo below or take a photo with your mobile device.
*Not required for quote.
Upload from your device.
Take a photo with your device. (available for mobile devices)

Just in case...
Who is the responding fire department?
How many miles to nearest fire station?
How many feet to nearest fire hydrant?
Is the home in a flood zone?

YES NO
Would you like to add earthquake coverage? *

YES NO
I am not interested in earthquake coverage for my home? (sign below)

Clear
Do you have any "scheduled property to add to the policy?" *

YES NO
Scheduled property is for highcost items that would go above and beyond your coverages. Examples include jewelry, guns, silver, china, and art.
List property and values. A recent appraisal may be required.

Do you need a quote for any of the following? (select all that apply.) *

Motorcycle Boat Motor home / Travel Trailer ATV None of these

Umbrella Insurance Quote
An umbrella insurance policy extends well beyond your home and auto insurance. You’ll have the flexibility to select a liability limit that best protects your assets.

You may also be covered for the following:

-Personal injury coverage: for claims of libel, slander, defamation of character and more
-Worldwide coverage: for incidents that happen abroad
-Vacation rental liability: protection for accidents involving boats, jet skis, scooters and other rentals
-Defense coverage: for legal fees and court costs
Are you interested in Umbrella Insurance? *

YES NO
Sign below to confirm that you are declining an Umbrella Quote.

Clear

Life Insurance Quote Request
The purpose of life insurance is to provide financial protection to surviving dependents after the death of an insured. For many people, it also involves purchasing the right amount of life insurance to protect their family's lifestyle. Life insurance can help reduce the financial impact on your loved ones in the event of your death.
Are you interested in a life insurance quote, today? *

YES NO
Sign below that you are declining a quote for life insurance.

Clear

Final Steps
How did you hear about The Murray Insurance Agency? *

Current Client Previous Client Referral Insurance Search
Who referred you? *
Name
What search engine? *
Google, Yelp, Facebook, etc.
Have you visited our facebook page?
Check it out before you leave!
This is the best way for you to get to know us!
Agent Preference?

First Available Agent
Is there anything else you would like to let us know? Here's your chance!
Keep in mind: No coverage will be bound by submitting this request.
An agent will contact you as soon as possible.
If you need immediate assistance call the office at 270-753-4751
Quoting insurance for new clients is an honor and privilege at our agency. We work hard to earn a reputation of great service. As our way of saying thank you, for giving us a chance, we created our “Quotes for the Community” program. We love supporting the philanthropic efforts in our community, so we’ve tied quoting and giving together.

Here’s how it works:
Each time we have a new potential client request a quote, we will donate, in their name, $10 to the charity of the quarter. No obligations!
It really is that simple!
Should be Empty:

Contact Info

Personal Information

Spouse

Auto Quote Request

History

Policy Information

Prior Insurance

Home Insurance Quote Information

Residents Information

Property Information

Mobile Home Information

Structure Information

History

Just in case...

Motorcycle Insurance Quote Request

Cycle Information

Boaters Insurance Quote Request

Boat Information

Motor Information

Trailer Information

Motor Home / Travel Trailer Insurance Quote Request

Vehicle Information

ATV Insurance Quote Request

ATV Information

Umbrella Insurance Quote

Life Insurance Quote Request

Final Steps