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Insurance Quote New Version

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Name*
First Last
Email*
Phone*
Comments
Address
Street Address Address Line 2 City State ZIP Code
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
Amount of Liability
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
Property Damage Liability
Medical Payments
Uninsured Motorist Liability
Uninsured Motorist Property
Underinsured Motorist Liability
Underinsured Motorist Property
Comprehensive Deductible
Collision Deductible
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
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
Type
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.

Insurance Quote New Version

Life Insurance

Homeowner Insurance

Auto & Motorcycle Insurance

Commercial Insurance

Medical – Group Insurance

Flood Insurance

Renters Insurance

Condominium Insurance

UPDATES:

Individual Health Insurance

Other Insurance