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Name
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Email
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Phone
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Comments
Address
Street Address
Address Line 2
City
Alabama
Alaska
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Armed Forces Americas
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Coverage(s) you are interested in:
Auto/Motorcycle Insurance
Homeowners Insurance
Commercial Insurance
Condo Insurance
Life Insurance
Medical - Group Insurance
Medical - Individual Health
Renters Insurance
Flood Insurance
Other
Life Insurance
Life Insurance Information
Type
Amount of Death Benefit
Insured Information
Date of Birth
Use Tobacco
Yes
No
Gender
Male
Female
Spouse Insurance Information
Spouse to be insured?
Yes
No
Spouse date of birth
Spouse use tobacco?
Yes
No
Gender
Male
Female
Children
Yes
No
Disability Insurance Information
Occupation
Duties
Earnings
Earnings Frequency
Weekly
Monthly
Yearly
Other Disability Coverage?
Yes
No
Other Disability Coverage Type
Individual
Group
Disability Benefits to be Quoted
Elimination Period STD
Percentage Payable STD
Maximum Monthly Benefit STD
Duration of Benefits STD
Elimination Period LTD
Percentage Payable LTD
Maximum Monthly Benefit LTD
Duration of Benefits LTD
Homeowner Insurance
Current Insurance Information
Company Name
Current Annual Premium
Current Coverage
Expiration Date
Deductable Desired
$100
$250
$500
Amount of Liability
$100,000
$200,000
$500,000
$1,000,000
Earthquake Coverage Desired?
Yes
No
Have you filed for bankruptcy within the past 7 years?
Yes
No
Dwelling Information
Year Constructed
Square Footage
How many floors?
1 Story
1.5 Story
2 Story
Bi-Level
Tri-Level
Other
Other
Type of Construction
Wood
Stucco
Masonry
Brick Veneer
Aluminum Siding
Other
Other
Other Features (check all that apply)
Dead Bolts
Smoke Detectors
Fire Extinguisher
Central Station Fire Alarm
Central Station Burglar Alarm
Home Located within 5 miles of Fire Station
Home Located within 1000 feet of a Fire Hydrant
Swimming Pool
Trampoline
Home located within City Limits
Claims - List any claims in past 3 years:
1. Date of Claim
Amount Paid
Claim Type
Description
2. Date of Claim
Amount Paid
Claim Type
Description
3. Date of Claim
Amount Paid
Claim Type
Description
Personal Property - Estimated value of your personal property:
Jewelry & Watches
Furs
Silver
Firearms
Stamp and Coin Collections
Fine Arts and Breakable Items
Auto & Motorcycle Insurance
Current Insurance
Do you presently have Auto Insurance?
Yes
No
Company Name
Renewal Date
Annual Premium
Have you been cancelled or non-renewed in the past 6 months?
Yes
No
Coverages
Bodily Injury Liability
50/100
100/300
250/500
Property Damage Liability
25,000
50,000
100,000
Medical Payments
1,000
2,500
5,000
Uninsured Motorist Liability
50/100
100/300
250/500
Uninsured Motorist Property
25,000
50,000
100,000
Underinsured Motorist Liability
50/100
100/300
250/500
Underinsured Motorist Property
25,000
50,000
100,000
Comprehensive Deductible
No Coverage
250
500
1,000
Collision Deductible
No Coverage
250
500
1,000
Rental Reimbursement
Yes
No
Towing & Labor
Yes
No
Licensed Drivers - (Primary Driver)
Name on License
License State
Gender
Male
Female
Relationship to Applicant
Marital Status
Married
Single
Divorced
Widowed
Age
Occupation
Good Student
Yes
No
Driver Training
Yes
No
Tickets and Accidents (last 5 years)
Name on License
License State
Gender
Male
Female
Marital Status
Married
Single
Divorced
Widowed
Age
Relation to Applicant
Occupation
Good Student
Yes
No
Driver Training
Yes
No
Tickets and Accidents (last 5 years)
Other Drivers - Please provide the names and birthdates of any other residents in your household licensed to drive.
1. Name
Date of Birth
Drivers License Number
2. Name
Date of Birth
Drivers License Number
3. Name
Date of Birth
Drivers License Number
Additional Vehicle(s) Information
Year
Make
Model
VIN
License State
Annual Mileage
# of Doors
4-Wheel Drive
Yes
No
Alarm System
Yes
No
Air Bags
Yes
No
Anti-Lock Brakes
Yes
No
Auto-Seatbelts
Yes
No
Additional Vehicle(s) Information
Year
Make
Model
VIN
License State
Annual Mileage
# of Doors
4-Wheel Drive
Yes
No
Alarm System
Yes
No
Air Bags
Yes
No
Anti-Lock Brakes
Yes
No
Auto-Seatbelts
Yes
No
Commercial Insurance
General Information
Business Name
Business Phone
Fax
Current Insurance Company - (not agency)
Company Name
Policy Expiration Date
Current Insurance Coverages
Current Coverages
Bond
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
Group Health
Group Life
Professional Liability
Workers' Compensation
Other
Other
Business Information
# of Full-Time Employees
# of Part-Time Employees
How long in Business? (yrs)
How many locations?
Please give a brief description of your business and clientele
Property/Premises Information
Address
Occupancy Status
Owner
Tenant
Year Built
% Occupied
Sprinklers
Yes
No
Construction Type
Frame
Brick Veneer
Stucco
Metal
Concrete
Stories
# Basements
Sq. Footage
Burglar Alarm
Yes
No
Building Value
Contents
Other Property (specify)
Insurance Information
Other
Annual Gross Sales: (before taxes)
Number of Employees
Annualized Payroll
Cost of any Subcontracted Work
Limits Requested
$300,000
$500,000
$1,000,000
$2,000,000
Describe any claims you've had in the past 5 years
Additional Comments
Medical - Group Insurance
General Information
Name of Business
Nature of Business
Business Phone
Fax
Life and AD&D Coverage
Number of Employees
Number of Employees Eligible
Current Carrier
Renewal Date
Current Rate
Renewal Rate
Flat Amount
Group Health Coverage
Number of Employees
Number of Employees Eligible
Current Plan
HMO
POS
PPO
Indemnity
Plan to Quote
HMO
POS
PPO
Indemnity
Desired Deductable
Desired Co-Pay
Desired Co-Insurance
Group Dental Coverage
Number of Employees
Number of Employees Eligible
Class A Deductable
Class B Deductable
Class C Deductable
Class A Co-Insurance
Class B Co-Insurance
Class C Co-Insurance
Calendar Year Maximum
Group Disability Coverage
Number of Employees
Number of Employees Eligible
Current Plan
STD
LTD
Current Carrier
Renewal Date
Current Rates STD
Renewal Rates STD
Elimination Period STD
Percentage Payable STD
Maximum Benefit STD
Duration Benefits STD
Current Rates LTD
Renewal Rates LTD
Elimination Period LTD
Percentage Payable LTD
Maximum Benefit LTD
Duration Benefits LTD
Comments - Employee census information including Date of Birth, Sex, Job Title and Earnings will be required. Loss Information will be helpful and may be required on groups over 100 lives.
Please note any other pertinent information or requests for coverages
Flood Insurance
Property Location
Address
City
State
Zip
County
Renters Insurance
General Info
Date
Property Address
Unit#
Current Address
Complex Name
DOB
ss#
Occ
Employer
Spouse Name
DOB
ss#
Employer
Occ
Condominium, Duplex, Apartment, House
Insured Value $
Year built
Living Area Sq Footage
Construction
Gated?
#stories
Number of units
Floor Location
Bathrooms
Fireplace
Porch
If yes, Sq Footage
Alarm System
Central
Local
Sprinklers
Deadbolts
Smoke Alarms
Extinguishers
Any bankruptcies, Repossession, Foreclosures?
Date
Prior Ins.
Policy#
Claims
Dates
Condominium Insurance
General Info
Date
Closing Date
Complex Name
DOB
SS#
Occupation
Employer's Name
Employer's Address
Spouse Name
DOB
SS#
Occupation
Employer
Condo Information
Occupancy
Primary
Rental
Secondary
Type
Condominium
Duplex
Townhouse
Insured Value
Contents
Year Built
Sq. Feet
Construction
Gated Community
# Bathrooms
# Car Garage
Stories Bldg
Units Bldg
Stories Condo
Floor Location
Screened Porch
Fireplace
Pets
Bite History
Central Alarm System
Fire Sprinklers
UPDATES:
Roof
Plumbing
Electrical
AC/Heating
Bankruptcy, Repossession, Foreclosure?
Date
Prior Insurance
Policy #
Exp. Date
Claims
Date/Cause
Additional Interest
Mortgagee Clause
Contact Name
Phone #
Fax #
Escrowed?
Yes
No
Loan #
Association Name
Address
Contact Name
Phone #
Fax #
Individual Health Insurance
General Info
Status
Single
Family
Other
Age(s)
Deductible
$1,000
$1,500
$2,000
$5,000
Medical Information
Other Insurance
General Info
Please describe what you are looking for
Disclaimer Notice
- The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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