Auto Insurance Quote

1
Bundle & Save! What are you looking to protect?* This field is required.
Auto
Property: Homeowner's
Property: Renter's
2
What's your name?* This field is required.Your personal information will ALWAYS be confidential & secured!
First Name
Middle Name
Last Name
3
When is your birthday?* This field is required.
Date
Month
Day
Year
4
What's your gender?* This field is required.
M
F
5
What's your marital status?* This field is required.
Single
Married
Divorced
Domestic Partner
Separated
Widowed
If Married, Spouse information will be required
6
What's your Driver's License Number?* This field is required.In order to offer you the most appropriate rate, we use information collected from consumer reporting agencies, such as your driving record, accident, violations, and claims history. Your Driver's License number is used as an identifier and to obtain your Motor Vehicle Record information in states where applicable.
7
What is your current employment status?* This field is required.
Employed
Self Employed
Full-time Student
Homemaker
Unemployed
Retired
8
What do you do for a living?* This field is required.If employed or self-employed, what does your job/business consist of?
9
Any additional drivers needing coverage? If so, add them below, if not click NEXTIf more than 4 additional drivers, please add their information at the end of the questionnaire
First Name, Last Name & Date of Birth (MM/DD/YY)
Driver's License Number
First Name, Last Name & Date of Birth (MM/DD/YY)
Driver's License Number
First Name, Last Name & Date of Birth (MM/DD/YY)
Driver's License Number
First Name, Last Name & Date of Birth (MM/DD/YY)
Driver's License Number
10
Where do you live?* This field is required.This should also be where the car(s) are parked regularly overnight.
Address Line 1
Address Line 2
City
Please Select
Please Select
AL
AK
AZ
AR
CA
CZ
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
11
How many years have you lived at your current address?
Less than 1
1
2
3
4
5 or more
12
What vehicle would you like to protect?* This field is required.We'll need you to upload a picture of every VIN that will be insured. (This will produce the most secure outcome to avoid typo's, misunderstandings or issues in the future.)
Year
Make
Model
VIN #
13
Vehicle Ownership* This field is required.Lien holder information can be added in notes at the end of the questionnaire
Owned
Financed
Leased
14
How long have you owned this vehicle?* This field is required.
Less than 1 month
At least 1 month but less than 1 year
At least 1 year but less than 3 years
At least 3 years but less than 5 years
5 years or more
15
What is the primary use of your vehicle?* This field is required.
Pleasure
Commute (to work or school)
Business (sales calls, etc.)
16
Around how many miles do you drive in a year?* This field is required.An estimate is fine
17
Any additional vehicles needing coverage? If so, add them below, if not click NEXT We'll need you to upload a picture of every VIN that will be insured. This will produce the most secure outcome to avoid typo's, misunderstandings or issues in the future.
Year, Make, Model
VIN # (17 Alphanumeric digits)
Year, Make, Model
VIN # (17 Alphanumeric digits)
Year, Make, Model
VIN # (17 Alphanumeric digits)
Year, Make, Model
VIN # (17 Alphanumeric digits)
18
Are all the vehicles registered to you in the state of FL? If not, will they be in the next 30 days?
YESNO
19
Do you own or rent your home?* This field is required.Consider adding a renter's quote and save! (It actually works!)
Own
Rent
20
Do you currently have auto insurance?* This field is required.Select "Yes" if you are an insured driver on any policy.
Yes
No, my insurance expired
No, I did not have a need for insurance
No, I was living outside the country
No, I was driving without insurance
21
If you chose YES on the prior question, we need more information about your current coverage. Please answer the following questions OR upload your current auto insurance declarations page on the next prompt.
22
Current or prior auto insurance declarations page(A screenshot will suffice.)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
23
If you did not opt-in for the prior prompt, please provide us your current or prior auto insurance information.
Who is your current or prior auto insurance provider?
How many years have you been with your current auto insurance provider?
Please Select
Please Select
Not sure (This answer will limit what carriers we can offer you)
$10,000/$20,000
$15,000/$30,000
$25,000/$50,000
$50,000/$100,000
$100,000/$200,000
$100,000/$300,000
$250,000/$500,000
$500,000/$1,000,000
$1,000,000$1,000,000 or higher
What are your current bodily injury limits?
24
How old were you when you first obtained your driver's license in the U.S., it's territories, possessions or Canada?* This field is required.
25
What's the highest level of education that you've completed?* This field is required.Getting a complete picture of your education can help us find you even more savings!
Less than High School
Vocational or Trade School
High School
Currently in college pursuing Associates
Associates
Currently in college pursuing Bachelors
Bachelors
Currently in college pursuing Graduate degree
Masters
Doctors
Lawyers
PhD
26
Are you affiliated with any of the following organizations?* This field is required.
Military
State/Local Government
Federal Government/Postal Service
None of the above
27
Have any of the following occurred?

Accidents (regardless of fault) in the last 5 years?

Accidents (regardless of fault) by anyone who was not listed on your insurance policy in the last 5 years?

Traffic Tickets in the last 5 years?

DUIs in the last 10 years?

Suspensions or Revocations in the last 10 years?

If so, please add incidents in the following prompt
28
Add Incidents If applicable (If not, click NEXT.) - Date & Incident type (Accident - Conviction - Suspension?)
29
When do you want your coverage to begin? * This field is required.Some carriers allow for early termination and will be forced to refund you. Let your agent know if you would like to take this approach, so we confirm if possible.
Date
Month
Day
Year
30
Please add anything you'd like our agents to be aware ofExample: Full coverage only on the 2022 Chevy Camaro, lien holder information, additional drivers' information etc.
Huge
Large
Normal
Small
Ok
Ok
31
Email Address* This field is required.The email address that you provide will be kept confidential, secure and will not be sold or redistributed.
pandc@comfortif.com
32
Phone Number * This field is required.The phone number that you provide will be kept confidential, secure and will not be sold or redistributed.
33
Preferred method of contact* This field is required.
E-Mail
Phone Call
Text Message
34
Best time of day to reach you* This field is required.
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Hour
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Minutes
AM
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PM
35
How did you hear about us?* This field is required.
Google, Yelp, Facebook, Instagram, Radio Ad, Friend, Agent etc.
36
Agent who referred youIf applicable
Alejandro Kan
Alexandra Cruz
Dagoberto Cruz
Daniela Guere
Deilis Carrazana-Galan
Glenda Mendez
Joshua Amador
Marina Guadamuz
Oscar Flores
Robert Bonilla
Other
37
Other (Please Specify)
38
DISCLAIMER: By submitting your information, you agree that a representative from the agency will contact you at the above-listed email or phone number. You understand that consent is not a condition of purchase and that this does not guarantee issuance of coverage.* This field is required.
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