Quote

Freedom Insurance Group Quote Form

By requesting an insurance quote, you acknowledge and agree that the information provided will be used by Freedom Insurance Group to generate a personalized quote for you. This may include collecting and analyzing personal data such as your name, address, contact details, and other relevant information. We are committed to protecting your privacy and will handle your information in accordance with our privacy policy. By proceeding, you consent to the use of your information for the purpose of obtaining an insurance quote By filling out this form, you consent to be contacted by Freedom Insurance Group via text and/or phone call.
Contact Information
Name*

First NameLast NameSuffix
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Sex*

FemaleMaleNon-Binary
Please select the type of quote. (Check all that apply)*

AutoHomeLifePetRentersOther
Other type of insurance.*
Please include as much information as possible.
Auto Insurance
Driver's License Status (check all that apply)

I don't have a driver's licenseMy driver's license is suspended or revokedI need SR22I don't own a car, but still need insuranceI have a valid driver's license
Driver's License State*
Driver's License Number*
A quote cannot be completed without this information.
Have you had any tickets or accidents in the last five (5) years?*
Upload most recent Declaration Page

You do not need to complete any other information if your declaration page is uploaded.
Cancelof
Are any coverages or vehicles different from the current declaration page?
Optional
Current Provider

Auto Insurance
Who is your current insurance company?*

I don't have insurance right nowCompany Name
When did your policy cancel?

MonthDayYear
Date
When does your policy renew? *

MonthDayYear
Date
How do you pay your insurance premium?*
Do you have additional household members and/or drivers to include?*

YesNoUnsure
Additional Driver(s)*
Please explain.*
Vehicle Information*
Optional Coverages
Check all that apply.*

I rent.I own my home.I own properties which are rented to others.I have other properties for personal use.Other
Home Insurance
Renters Insurance
Current Provider

Property Insurance
Who is your current insurance company?*

I don't have insurance right now.Company Name (Text box will appear once selected.)
How do you pay your insurance premium?*
Upload most recent Declaration Page

You do not need to complete any other information if your declaration page is uploaded.
Cancelof
How much personal property coverage do you currently have or need?*

$10,000 - $20,000$25,000 - $50,000$50,000 - $100,000More than $100,000I'm not sure.
Does your landlord require you to have insurance?*
How many units are in your building?*
Property Information
Check any that apply.*

I'm purchasing a new home.My home is being built.I have a Rent-To-Own contract.None
When do you expect to close?*

MonthDayYear
Date
Paste the link, if the property is listed online.
Upload the property details sheet.

Cancelof
Purchase date?

MonthDayYear
Date
I have additional household members to add.*

NoYes
Additional Household Members
Property Details
Life Insurance
What do you want life insurance to do for you? (Select all that apply)*

I want to help my family with funeral expenses and some financial supportI want my family to be fully taken care of for years after I passI want my mortgage to be coveredI’m not sure what I want from it
Death Benefit Amount*

$150k or Less$250k$500k$1 Million or moreUnsure
Monthly Budget
Dollar amount or price range
Insured Information
Check all that apply.*

I want insurance for myself.I want insurance for someone else.
Are you a U.S. Citizen?*
Place of Birth
City and State Or Country if Outside US
Sex*
Tobacco Use*
Height*
Weight*
Occupation/Title
Est. Income
Primary Beneficiary

First NameLast Name
Medical Complications*

CancerHeartDiabetesAIDS/HIVOtherNone
Describe Medical Issues
Date of Diagnoses, Type, Other Relevant Information
Any Medications Used
Name of Prescription, Dosage, Frequency
Person to be insured*
Pet Insurance
Pet Information
Pet Details
Additional Information
Highest level of education completed?
Some carriers offer a discount.
Occupation and Employer
Some carriers offer a discount.
Other Information
Anything that might be relevant for your quote.
How did you hear about us?*
Should be Empty:

Freedom Insurance Group Quote Form

Contact Information

Auto Insurance

Current Provider

Home Insurance

Renters Insurance

Current Provider

Property Information

Life Insurance

Insured Information

Pet Insurance

Pet Information

Additional Information