Insurance Quote

Personal Information

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Quote*

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Business Insurance

Business to be Insured

Business Type*

Interest of Premises

Program

Limits of Insurance and Optional Coverages

Construction

Masonry

Exterior Glass

Sign

Systems Breakdown/Boiler & Machinery

Non-owned or hired automobile

3 Year Prior Carrier
Year 1
Year 2
Year 3
Loss History

Auto Insurance

Driver Information

Do you currently own or rent your home?

Driver #1

Sex

Marital Status

Driver #2

Sex

Marital Status

Driver #3

Sex

Marital Status

Driver #4

Sex

Marital Status

Driver History

Have you or any other driver in your household:

Had a ticket in the last 3 years?

Had a license suspended or revoked in the last 6 years?

Had a financial responsibility filing in the last 6 years?

Made any claims in the last 5 years?

Vehicle Information
Vehicle #1

Is the vehicle driven to school or work?

Is the vehicle in any way modified or customized?

Is there any existing damage to the vehicle?

Is the vehicle kept at an address other than that listed above?

If yes, the following fields are requested:

Vehicle #2

Is the vehicle driven to school or work?

Is the vehicle in any way modified or customized?

Is there any existing damage to the vehicle?

Is the vehicle kept at an address other than that listed above?

If yes, the following fields are requested:

Vehicle #3

Primary Driver

Is the vehicle driven to school or work?

Is the vehicle in any way modified or customized?

Is there any existing damage to the vehicle?

Is the vehicle kept at an address other than that listed above?

If yes, the following fields are requested:

Vehicle #4

Primary Driver

Is the vehicle driven to school or work?

Is the vehicle in any way modified or customized?

Is there any existing damage to the vehicle?

Is the vehicle kept at an address other than that listed above?

If yes, the following fields are requested:

Coverage Options
Coverage Deductibles
Vehicle #1
Vehicle #2
Vehicle #3
Vehicle #4

Home Insurance

Structural Information
What is the structure of the following?
How many of the following do you have in your home?
Do you have the following in your home?

Swimming pool

Trampoline

Kerosene, Wood, or Oil Stove

Dog

Livestock

Unusual or Exotic Pets

Is your home located:

Within 1000 feet of a fire hydrant?

Within 5 miles of the fire station?

On a hillside?

Close to a body of water or susceptible to flooding?

General Questions

Is business conducted on the premises?

Does anyone in your home smoke?

Did you experience any loss or claims in the last 5 years?

Protective Devices

Smoke Detectors?

Fire Extinguishers?

Deadbolt Locks?

Additional Information

Gated community with a security guard:

Neighborhood watch program:

Senior citizen discount (all occupants age 55 or above):

Homeowners Coverages & Deductibles
Additional Data

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Optional Questions

Do you have any special interests or hobbies that could be considered a home based business?

Do you travel?

Do you travel outside of the United States?

When you travel, do you bring valuables such as watches, jewelry, or furs with you?

Do you buy things while traveling and want to know that they are immediately insured under your policy?

If your home were destroyed, would you want to rebuild it in the same location?

Do you have/want backup of sewers and drain coverage?


Life Insurance

General Questions

Sex

Are you a citizen of the United States?

Have you lived outside the United States during the last 3 years?

Do you plan to leave the United States for travel or residence during the next 3 years?

Do you currently work in a hazardous occupation?

Do you participate in any risky outdoor activities?

Do you fly as a pilot, co-pilot or crewmember of an aircraft?

Are you an active member of the military or military reserve?

Have you received three or more moving violations or had your driver's license suspended/revoked in the past 5 years?

Have you been found guilty of reckless driving or driving under the influence (DUI/DWI)?

Is there any family history of cardiovascular disease before the age of 60?

Have you had any health symptoms or been treated for any of the conditions listed below?

If Yes, please check those below which apply:

Do you have cancer?

Coverage Information

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