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Auto and Home Insurance Form

Oklahoma
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Name*
Gender*
Assigned sex at birth for underwriter purposes.
Date of Birth*

MonthDayYear
Driver's License*
State*
1st Person Occupation/Retired*
Other drivers in the household?*

YesNo
- Name
- Gender
- Date of Birth
  
  MonthDayYear
- Driver's License
- State
- 2nd Person Occupation/Retired
- Name
- Gender
- Date of Birth
  
  MonthDayYear
- Driver's License
- State
- 3rd Person Occupation/Retired
- Name
- Gender
- Date of Birth
  
  MonthDayYear
- Driver's License
- State
- 4th Person Occupation/Retired
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province / Region
  
  Zip Code
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province / Region
  
  Zip Code
- Who are you insured with?*
- Do you have a Mortgage?*
  
  YesNo
- Any Home Claims in the Past 3 Years?*
  
  YesNo
- If you have had a claim in the last 3 yrs?
  
  RoofWaterTheftAuto
- Roof type?
  
  Asphalt Shingles (most common)Class 3 Hail-Resistant ShinglesClass 4 Hail-Resistant ShinglesMetalClay Tile
- Age of your Roof (you can estimate)
  
  MonthDayYear
- Available Discounts
  
  Defensive Driving (Last 2Years)Fire ExtinguisherMonitored AlarmSmoke DetectorsAccident-Free 3 YearsCollege Degree DiscountFire Sprinkler SystemGreen
- Do you have any Dogs?*
  
  YesNo
- Do you have a Pool?*
  
  YesNo
- Do you have a Trampoline?*
  
  YesNo
- Property ownership*
  
  RenewalNew PurchasePending Offer
- Rent to others on a short-term basis?
  
  In-PartWhole
- Rent to others on a short-term basis?
- 1. VEHICLE YEAR, MAKE AND MODEL*
- 1. VEHICLE VIN NUMBER*
  PLEASE CAPITALIZE LETTERS
- Any Accidents, Violations, or Losses in the Past 5 Years?*
  
  YesNo
- LIEN HOLDER/ FINANCED*
  
  YesNo
- COVERAGE*
  
  LIABILITY ONLYCOMPREHENSIVE & COLLISION
- 2. VEHICLE YEAR, MAKE AND MODEL
- 2. VEHICLE VIN
  PLEASE CAPITALIZE LETTERS
- LIEN HOLDER/ FINANCED
  
  YesNo
- COVERAGE
  
  LIABILITY ONLYCOMPREHENSIVE & COLLISION
- 3. VEHICLE YEAR, MAKE AND MODEL
- 3. VEHICLE VIN
  PLEASE CAPITALIZE LETTERS
- LIEN HOLDER/ FINANCED
  
  YesNo
- COVERAGE
  
  LIABILITY ONLYCOMPREHENSIVE & COLLISION
- 4. VEHICLE YEAR, MAKE AND MODEL
- 4. VEHICLE VIN
  PLEASE CAPITALIZE LETTERS
- LIEN HOLDER/ FINANCED
  
  YesNo
- COVERAGE
  
  LIABILITY ONLYCOMPREHENSIVE & COLLISION
- What auto liability do you have?*
  
  50/100/50100/300/100250/500/250500/500/100Other
- Uninsured Motorist Bodily Injury:*
  
  Decline25/5050/100100/300250/500Other
- COMP: What auto comprehensive deductible do you have?*
  
  Decline5001000Other
- COLLISION: What auto collision deductible do you have?*
  
  Decline5001000Other
- Medical Payment*
  
  Decline$500$1,000$5,000$10,000$25,000
- Roadside Assistance*
  Provides coverage if the insured's car is disabled due to a covered emergency and is available 24/7 in the United States and Canada. Towing Covered vehicle can be towed within a 15-mile radius, or to the nearest qualified repair facility. Winching Service Pulling a covered vehicle out of an area with a motor-powered cable or chain. Usually offered when a vehicle is trapped in mud, snow, water, or sand within 100 feet of road or highway. Battery Jump-Start Battery failure Fuel Delivery Fuel delivered directly to the covered vehicle. The insured is responsible for the cost of fuel. Locksmith Service Keys are lost, stolen or accidentally locked inside the covered vehicle, we will dispatch a qualified service provider. The insured is responsible for the cost to replace the keys. Flat Tire Change On Scene Labor Related to disablement, up to one hour. Trip interruption Provides daily maximums of $100 for lodging, $50 for alternative transportation, and $50 for food while the insured vehicle is being repaired, up to $500 per occurrence. The mechanical breakdown or accident must occur more than 100 miles from the insured's primary residence.
- Rental Car*
  Rental Reimbursement pays for rental car fees, up to the limit selected, if the customers' car is damaged and undriveable. This only applies to covered losses and not general maintenance. Please review the policy contract for complete coverage information. Rental Reimbursement can only be purchased on a car that has both comprehensive and collision.
- When does your insurance expire?
  
  MonthDayYear
- When do you want your policy to start?*
  
  MonthDayYear
- Email*
  
  Confirmation Email
- I'd like a quote for the following insurance products:
  
  DentalLifeCyberUmbrellaJewelryPet
- NOTES (ADD MORE VEHICLES)
- Upload your old policy for a side-by-side comparison.
  
  If you would like a side-by-side comparison, please send us your current policy documents. Accepted file types: jpg, gif, png, pdf
  Cancelof
- How did you hear about us?*
  
  GoogleChatGpt or other AIReferralYahooFacebookOther
- How would you like us to contact you?*
  
  CallEmailTextEmail & Call
- Phone Number (We will not call you unless you have requested a call.) *
  Please enter a valid phone number. We need it for your quote.Format: (000) 000-0000.
- Please verify that you are human*
- Should be Empty:

Auto and Home Insurance Form