Insurance Request Form

Insurance Quote Request

Thank you for choosing Then Insured by Mr Then Consulting.Please complete this quick form so we can shop around with trusted carriers like Progressive, Safeco, National General, Geico, and more to get you the best rate. Your info is secure and only used to provide your insurance quote.📲 Questions? Text/call 401-267-8436
Insurance Request Form
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Gender
SingleMarriedWidowedDivorcedIt's Complicated
Drivers License Number and State
Current Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
State for Insurance*
AutoRentersHomeLifeUmbrellaLandlord (Rental Property)CommercialPetToys (ATV, Boat, Etc.)
YesNo
Effective Date for Insurance

MonthDayYear
Date
Upload Relevant Documents (e.g., Drivers License, Declarations Page)

Upload a File

Cancelof
Additional Notes or Requests
What State do you need Insurance In?
AutoRentersHomeLifeUmbrellaLandlord (Rental Property)Commercial - General Liability (GL)Commercial - Business Owners Policy (BOP)Commercial - Workers CompCommercial - Commercial AutoCommercial - E&O / Professional LiabilityCommercial - Cyber LiabilityCommercial - Commercial UmbrellaPetToys (ATV, Boat, Etc.)Other
Commercial AutoCommercial PropertyBuilders RiskCommercial General LiabilityCommercial UmbrellaBusiness Owner's PolicyWorker's CompensationProfessional Liability / Errors & OmmissionsCyber LiabilityCommercial CrimeEmployment Practices LiabilityBusiness Income Insurance/Business InterruptionBondsOther
Term LifeWhole LifeUniversal LifeI'm not sure
YesNo
If Insured, with who? For How Long and How Much? Also please include Policy Number and Expiration Date
Ex. ABC Insurance - 10 years - 310/mo - 1234567 - 03/10/2029
YesNo
What Effective Date would you like?

MonthDayYear
When do you want your policy to begin? Putting it out 1-2 weeks can usually get you a discount.
Legal Name

First NameMiddle NameLast NameSuffix
Date of Birth

MonthDayYear
Date
Gender
SingleMarriedWidowedDivorcedIt's ComplicatedOther
No High School Diploma or GEDHigh School Diploma or GEDVocational / Trade School or Military TrainingCompleted Some CollegeCurrently In CollegeObtained College DegreeGraduate Work or Graduate Degree
Height (inches)
ex. 5'11"
Weight (pounds)
ex. 250 LB
OwnRentOther
Your Drivers License # and State
Ex. 1234567 - Rhode Island
Your Drivers Expiration and Status
Ex. 12/10/2029 - Active/Suspended
What is your email address?

Confirmation Emailexample@example.com
Best Phone Number to Reach You
Ex. 401-123-4567Format: (000) 000-0000.
Occupation/Job
Ex. Engineer/Salesperson
Name of Employer & Address
Ex. ABC Company -123 ABC Company Way Providence RI 02908
YesNo
YesNo
Describe any health issues
Spouse Legal Name

First NameMiddle NameLast NameSuffix
Spouse Gender
Spouse Date of Birth

MonthDayYear
Date
Best Phone Number to Reach Your Spouse
Ex. 401-123-4567Format: (000) 000-0000.
What is your Spouse DL and State?
Ex. 13456 - RI
What is your Spouse email address?

Confirmation Emailexample@example.com
No High School Diploma or GEDHigh School Diploma or GEDVocational / Trade School or Military TrainingCompleted Some CollegeCurrently In CollegeObtained College DegreeGraduate Work or Graduate Degree
Spouse Occupation/Job
Ex. Engineer/Salesperson
Spouse Name of Employer & Address
Ex. ABC Company -123 ABC Company Way Providence RI 02908
Your Current Address or Address you'd like Insured

Street Address

Street Address Line 2

CityState

Zip Code
YesNo
YesNo
Your Previous Address

Street Address

Street Address Line 2

CityState

Zip Code
Your Mailing Address (if different than Current)

Street Address

Street Address Line 2

CityState

Zip Code
RecreationalCommercialOtherOther
Year
Enter the year of your ATV, Boat, or Snowmobile
Make
Enter the make of your ATV, Boat, or Snowmobile
Model
Enter the Model of your ATV, Boat, or Snowmobile
Additional Features or Coverage Requirements
Specify any additional features or coverage requirements
Business Name
Ex. ABC LLC
Business Industry
Ex. Janitorial Services - 561720
Business Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Physical Business Address

Street Address

Street Address Line 2

CityState

Zip Code
YesNo
YesNo
How many owners are there in your company?
1
Your Position in the Business
How many employees are there in your company? (Include Full Time and Part Time)
What is your employee payroll for the next 12 months? (Include Full Time and Part Time)
What is your expected business revenue for the next 12 months?
Auto, Bat or Vehicle Cleaning or DetailingCommercial Window CleaningConstruction, Maintenance, Repair, Renovation, Or Property PreservationExterior Cleaning for Commercial Surfaces, Buildings, or StructuresHazardous Waste Cleaning or RemovalLaundry or Dry Cleaning ServicesPet or Animal GroomingSandblasting ServicesActuarial AdviceConstruction Management or AdviceCredit CounselingArchitecture or Engineering AdviceInsurance Placement or AdviceInvestment or Tax AdviceLaw Enforcement TrainingGeneral ContractingLand AcquistionLobbying or Political AdviceMergers and Acquisitions or Business ValuationsMining Consulting or AdviceOil, Gas or Petroleum Consulting or AdviceSafety Consulting or AdviceSales RepresentativeNone of the Above
300K500K600K1MM1.5MM2MM
300K500K600K1MM1.5MM2MM
25050010002500500010K
IncludeDon't Include
IncludeDon't Include
IncludeDon't Include
Business Property & Equipment Coverage Limit
Ex. $15,000
IncludeDon't Include
IncludeDon't Include
IncludeDon't Include
What is your Pet Age, Name, and Breed
Preferred Home Peril Deductible
How Many Cars Do You Wish to Insure?
Maximum of 6 Allowed
REJECT20K/40K (MA MINIMUM)25K/50K (RI,CT,NJ,GA MINIMUM)50K/100K (ME MINIMUM)100K/300K250K/500K500K/500K
REJECT20K/40K (MA MINIMUM)25K/50K (RI,CT,NJ,GA MINIMUM)50K/100K (ME MINIMUM)100K/300K250K/500K500K/500K
REJECTACCEPT
REJECTACCEPT
REJECTACCEPT
Reject2505001000150020002500
Reject25 Per Day30 Per Day35 Per Day40 Per Day50 Per Day70 Per DayHighest $ Per Day
Reject25003000500010000
Reject2505001000150020002500
Year Make and Model of Vehicle 1
Ex. #1 -2017 Toyota Corolla
Vehicle 1 - List VIN #'s if Available
Ex. 1234aBCD9X12EFRG7
OwnedLeasedFinanced
Year Make and Model of Vehicle 2
# 2 - 2010 Honda Pilot
Vehicle 2 - List VIN #'s if Available
Ex. 1234aBCD9X12EFRG7
OwnedLeasedFinanced
Year Make and Model of Vehicle 3
# 3 - 2010 Honda Pilot Odyssey
Vehicle 3 - List VIN #'s if Available
Ex. 1234aBCD9X12EFRG7
OwnedLeasedFinanced
Year Make and Model of Vehicle 4
# 4 - 2010 Toyota Tundra
Vehicle 4 - List VIN #'s if Available
Ex. 1234aBCD9X12EFRG7
OwnedLeasedFinanced
Year Make and Model of Vehicle 5
# 5 - 2011 Lexus 300
Vehicle 5 - List VIN #'s if Available
Ex. 1234aBCD9X12EFRG7
OwnedLeasedFinanced
Year Make and Model of Vehicle 6
# 6 - 2017 Porsche Macan
Vehicle 6 - List VIN #'s if Available
Ex. 1234aBCD9X12EFRG7
OwnedLeasedFinanced
If financed or leased, with who? And for how long?
Ex. 1. Santander Bank - 72 months - 2. BOA - 24 months
List PLATE # if Available
Ex. 12-AB543
YesNo
If Yes, list Name, DOB, DL #, DL State, Relation to you
Ex. John Smith - 03/01/1991 - 1234567 - RI - Spouse
Estimated Annual Mileage
Ex. 10k
YesNo
If Yes, Try to list any Dates and or Amounts you can remember or Details
Are you interested in enrolling in a telematics safe-driving discount program?
Many carriers offer optional programs such as Drivewise, Snapshot, RightTrack, or DynamicDrive. These programs use a mobile app or plug-in device to monitor driving habits like acceleration, hard braking, time of day, mileage, and phone use. Most drivers receive an immediate 10–15% discount, with the potential to earn up to 45% off at renewal based on driving behavior. (NOTE 95% of clients see a decrease in their premium at renewal)
Social Security Number
This is optional but will help get a more accurate rate.Ex. 123-45-6789
Business Federal Tax ID Number
This is optional but will help get a more accurate rate.Ex. 123-45-6789
Upload Relevant Documents like DL or Declarations Page

Browse Files
Ex. Copy of Driver's License and or Declarations Page or any Other Docs that will help us better quote you Cancelof
EmailTextPhone CallWhatsapp
Special Notes or Request (optional)
Here you can enter anything that wasn't asked or that you would like to request that wasn't on the form.
How did you hear about us?
Ex. My Realtor John Smith
To get you an accurate quote, we’ll need to run a few reports—like your driving record, claims history, and credit-based insurance score (where allowed). This helps carriers like Progressive, Safeco, National General, and others determine your rate and eligibility. By submitting this form, you authorize Then Insured by Mr Then Consulting and our partner carriers to access that information for quoting purposes.*

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Insurance Quote Request

Insurance Request Form