Home & Auto
Please take 5 minutes to complete this form in order for us to better assist you.
Person & Contact Details
Name:
*
First Name
Middle Name
Last Name
Phone Number:
*
Email:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Drivers License # and State:
*
Ex: 123456789 TN
Occupation:
*
Marital Status:
*
Single
Married
Engaged
Spouse:
First name
Middle Name
Last Name
Phone Number:
Please enter a valid phone number.
Email:
example@example.com
Date of Birth:
-
Month
-
Day
Year
Date
Drivers License # and State:
Ex: 123456789 TN
Occupation:
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long have you lived here?
0-1 years
1-2 years
2-3 years
3+ years
Prior Address if you have moved within the last 3 years:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Residence:
*
Own
Mortgage
Rent
Are you currently insured?
*
Yes
No
Current Carrier
*
Please put "N/A" if you currently do not have insurance
How long have you been insured with them?
If you are not sure, please make best guess.
What has you shopping for new insurance?
Coverage
Price
Service
Agent Relationship
Vehicle Details
We require some information about your vehicle to for an accurate quote.
Make of Vehicle
Example: Ford / Toyota / Volkswagen etc.
Model of Vehicle
Example: F-150 / Camry / Wrangler etc.
Year of Vehicle
VIN #
How long have you had this vehicle?
1 year or less
1-2 years
3+ years
Own or Finance
Own
Finance
Make of Vehicle (Spouses)
Example: Ford / Toyota / Volkswagen etc
Model of Vehicle (Spouses)
Example: Ford Bronco
Year of Vehicle (Spouses)
VIN # (Spouses)
How long have you had this vehicle?
1 year or less
1-2 years
3+ years
Own or Finance
Own
Finance
Is your Vehicle used for Personal and/or Business use?
*
Personal only
Business only
Personal and Business
Please Select- Security in Vehicle
Alarm
Push to Start (key nearby)
None
Have you had any claims in the past 3 years?
*
Yes
No
If yes, please give details of prior claims:
Home Details
We require some information about your home content to do an accurate quote.
When did you purchase this property?
-
Month
-
Day
Year
Latest Update on electrical, plumbing, and roofing?
Ex: 2015
Please select what safety features are applicable to your home:
Smoke Detector
Alarm - Reports to 24/7 surveillance team
Alarm - Sound only
Total value of all the content to be insured
Example: TV / Couch / Fridge / Washing Machine etc
Total value of all your jewelry to be insured
Value for jewelry such as an Engagement Ring
Do you have a dog?
Please leave blank if this does not apply to you.
Do we have permission to text you?
*
Yes
No
Upload Declaration Pages
Policy document that shows your current coverages. You can go ahead & submit now or email declaration pages to tanner@lighthouseinsures.com later if needed.
Current Policy Schedule
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