Personal Lines Quote Old Form

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Nearest Office Location

What type of insurance can we quote for you?**

Auto

Home

Condo

Mobile Home

Umbrella

Rental Property

Motorcycle/Slingshot/ATV

Golf Cart

Boat

Other

Do you currently have Auto Insurance**

We are no longer accepting drivers without current insurance.

How did you hear about us?

Internal Referral Sources

Who Referred You?

What other type of insurance can we quote for you?

Primary Contact Information

Name(Required)

First Last

Phone(Required)

Email(Required)

Date of Birth(Required)

Occupation

Marital Status

Single

Married

Divorced

Widowed

Spouse Information

Spouse will be considered driver #2 if quoting auto.

Name

First Last

Phone

Occupation

Date of Birth

Property Information

Address of location to be insured(Required)

Street Address City State ZIP Code

Years at current address

Not required, but speed up your quote process by attaching photos of the front, back and sides of the property.

Drop files here or

Max. file size: 39 MB.

Home/Condo Information

Property Type

New purchase or already own the condo/home?

New Purchase

Already Own

How do you use the dwelling?

My Primary Residence

My Secondary Residence

My Rental

What year was the dwelling built?

How many acres do you own?

What is the square footage of the home?

(not including basement or attic)

Is the home a:

1 level

1.5 level

2 level

What is the construction type of the dwelling?

Type of siding?

Foundation Type

Roof Material

Roof Shape

Year Roof Updated(Required)

Number of Full Bathrooms

Number of Half Bathrooms

What is your heating type?

What is your cooling type?

Do you have a fireplace?

Yes – Gas

Yes – Wood

Do you have a woodburning stove in the home?

Yes

Do you have a deck or patio?

Yes – Covered

Yes – Screened

Yes – Enclosed

Deck/Patio Size

Have there been any updates to the following:

Heating

Electrical

Plumbing

Year Heating Updated

Year Electrical Updated

Year Plumbing Updated?

Garage

Yes Attached

Yes Detached

Car Port

None

Garage

1 Car

2 Car

3 Car

4 Car

Not required, but speed up your quote process by attaching photos of the front, back and sides of the home.

Drop files here or

Max. file size: 39 MB.

Detached Structure

Detached Structures

Yes

Year Built

Detached Structure Sq. Footage

What Type of Structure?

What Other Type?

What is the siding type of the detached structure?

Other Exterior Material

Detatched Structure Roof Type

Other Roof Type

Detatched Building Roof Age

Is there a woodstove in the detached structure?

Yes

Is there a fireplace in a detached structure?

Yes – Gas

Yes – Wood

Detached Structures Used For Farming Purposes?

Yes

Do you have a swimming pool?

Yes

Swimming pool fenced and locked?

Yes

Diving Board or Slide?

Yes

Do you have a trampoline?

Yes

Trampoline Has A Net?

Yes

Any Pets?

Monitored Burglar/Fire Alarm?

Local

Monitored

None

Dog Breeds

If mixed please indicate type of mix.

Any bite history or security training?

Yes

Any Livestock?

Yes

Farming Operations?

Yes

Mobile Home

Width

Length

Tied Down

Yes

In Approved Mobile Home Park?

Yes

Name of Park?

On Private Land?

Yes

Manufacturer

Model

Serial #

Any attached additions?

Condition of Mobile Home

Excellent

Good

Poor

New purchase or already own the condo/home?

New Purchase

Already Own

How do you use the condo?

Primary Residence

Secondary Residence

Rental

Purchase Date/Closing Date

Purchase Price

Year Home Was Built

Sq Ft

On Over 5 Acres?

Construction Type

Frame Detail

Any updates to heating, electrical or plumbing?

Heating

Electrical

Plumbing

Year Roof Updated

Roof Material

Roof Shape

Year Heating Updated

Type of Update

Year Electrical Updated

Type of Update

Year Plumbing Updated?

Type of Update

Foundation

Finished Basement %

Garage

Yes Attached

Yes Detached

Car Port

None

Garage

1 Car

2 Car

3 Car

4 Car

Not required, but speed up your quote process by attaching photos of the front, back and sides of the home.

Drop files here or

Max. file size: 39 MB.

Detached Structures – MH

Yes

Detached Structure

Year Built

Detached Structure Sq. Footage

What Type of Structure?

What Other Type?

Detatched Building Exterior

Other Exterior Material

Detatched Structure Roof Type

Other Roof Type

Detached Structures Used For Farming Purposes?

Yes

Detatched Building Roof Age

Fireplace

Yes – Gas

Yes – Wood

Woodstove

Yes

Deck/Patio

Yes – Covered

Yes – Screened

Yes – Enclosed

Deck/Patio Size

Swimming Pool

Yes

Swimming Pool Fenced and Locked?

Yes

Diving Board or Slide?

Yes

Trampoline

Yes

Trampoline Has A Net?

Yes

Any Pets?

Monitored Burglar/Fire Alarm?

Local

Monitored

None

Dog Breeds

If mixed please indicate type of mix.

Any bite history or security training?

Yes

Farming Operations?

Yes

Any Livestock?

Yes

If so, what and how many?

Scheduled Personal Property

Jewelry

Furs

Firearms

Art

Cameras

Musical Instruments

Other

Total Value of Jewelry Owned?

Total Value of Firearms Owned?

Total Value of Art/Cameras/Furs/Musical Instruments Owned?

Valuable Items List (Click the + to add additional items)

Please list each item and include an appraised/estimated value. Only one item per row please.

Home Notes

Farming

Farming Type

Annual Farming Income

Current Carrier Information

Who is your current insurance provider?

Policy Expiration

MM slash DD slash YYYY

What is your liability limit?

Amount of coverage on dwelling

Deductible

What is your current premium?

Is your homeowners insurance escrowed?

Yes

Have there been any home claims in the last 5 years?

Yes

Claims

Include Date of claim, Type of claim (wind/hail/water/lightning/other), Amount paid.

Auto Information

Total number of driving-age household members

Total Vehicles in Home

Vehicle #1

Vehicle Year

Make

Model

VIN

Comprehensive Deductible

Decline Comp

$250

$500

$750

$1,000

$1,500

Collision Deductible

Decline Collision

$250

$500

$750

$1,000

$1,500

Business Use

Yes

Rideshare or Delivery?

Yes

Roadside

Yes

Decline

Rental Reimbursement

Decline

$50/Day

$75/Day

$100/Day

Vehicle #2

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Comprehensive Deductible

Decline Collision

$250

$500

$750

$1,000

$1,500

Collision Deductible

Decline Comp

$250

$500

$750

$1,000

$1,500

Business Use

Yes

Rideshare or Delivery

Yes

Roadside

Yes

Decline

Rental Reimbursement

Decline

$50/Day

$75/Day

$100/Day

Vehicle #3

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use

Yes

Rideshare or Delivery

Yes

Roadside

Yes

Decline

Rental Reimbursement

Decline

$50/Day

$75/Day

$100/Day

Comprehensive Deductible

Decline Comp

$250

$500

$750

$1,000

$1,500

Collision Deductible

Decline Collision

$250

$500

$750

$1,000

$1,500

Vehicle #4

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use

Yes

Rideshare or Delivery

Yes

Roadside

Yes

Decline

Rental Reimbursement

Decline

$50/Day

$75/Day

$100/Day

Comprehensive Deductible

Decline Comp

$250

$500

$750

$1,000

$1,500

Collision Deductible

Decline Collision

$250

$500

$750

$1,000

$1,500

Vehicle #5

Vehicle Year

Vehicle Make

Vehicle Model

VIN

Business Use

Yes

Rideshare or Delivery

Yes

Roadside

Yes

Rental Reimbursement

$50/Day

$75/Day

$100/Day

Comprehensive Deductible

Decline Comp

$250

$500

$750

$1,000

$1,500

Collison Deductible

Decline Collision

$250

$500

$750

$1,000

$1,500

Driver #1 (Named Insured)

Drivers License

Any tickets or accidents in the last 5 years?

Date

Description

Driver #2 (Spouse)

Drivers License

Any tickets or accidents in the last 5 years?

Date

Description

Driver #2

Name

First Last

Drivers License #

Date of Birth

Relationship to you

Spouse

Child

Parent

Other

Occupation

Any tickets or accidents in the last 5 years?

Date

Description

Driver #3

Name

First Last

Date of Birth

Drivers License

Relationship to you

Spouse

Child

Parent

Other

Occupation

Student

Yes

Good Student Disocunt (GPA)

Any tickets or accidents in the last 5 years?

Date

Description

Driver #4

Name

First Last

Date of Birth

Drivers License

Relationship to you

Spouse

Child

Parent

Other

Occupation

Student

Yes

Good Student Disocunt (GPA)

Any tickets or accidents in the last 5 years?

Date

Description

Driver #5

Name

First Last

Date of Birth

Drivers License

Relationship to you

Spouse

Child

Parent

Other

Occupation

Student

Yes

Good Student Disocunt (GPA)

Any tickets or accidents in the last 5 years?

Date

Description

Current Auto Policy Information

Med Pay

$1,000

$5,000

$10,000

$25,000

Liability Limits

$25,000/$50,000/$25,000

$50,000/$100,000/$50,000

$100,000/$300,000/$100,000

$250,000/$500,000/$250,000

$500,000/$500,000/$500,000

Current Auto Insurer Name

Current Policy Expiration Date

MM slash DD slash YYYY

Length of Time with Current Auto Insurer

Towing/Rental Reimbursement

Yes

Current Annual Premium

If monthly, multiply by 12, if semi-annual, multiply by 2, etc.

Rental Property

Rental Property Address

Street Address City State ZIP Code

Short-term rental? (VRBO, Air BnB, etc.)

Days rented per year

Occupany Status

Days owner occupied per year

Personal Property Coverage Requested

Year Built

Under Construction?

Square Feet

Stories

Construction Type

What type of siding?

Roof Type

Age of roof

Foundation

Garage

Garage Type

# of baths

Any unfinished areas in your home?

Please specify the unfinished area(s)

Fireplace

Wood Burning Stove

Central Heat/Air

Heat/Air Type?

Alarm

Smoke alarm

Dead bolt

Monitored fire & burglar alarm

Animals

What kind of animals?

Trampoline

Trampoline Safety

Fenced

Netting

Swimming Pool

Pool Safety

Fenced

Locked

Current Carrier

Condition of home

Motorcycle/ATV

Name of Primary Driver

First Last

Has Driver Completed Safety Course?

Yes

Licensed Motorcycle Endorsement

Yes

Drivers License #

Tickets or accidents in last 5 years?

Years Experience

Vehicle Type

Motorcycle

Slingshot

ATV

Number of Wheels

Usage

Year

Make

Model

VIN

CC's

Umbrella

How many homes do you own?

This includes primary, secondary, vacation, rental and investment properties.

How many home/renters claims have you made in the last 5 years?

How many vehicles do you own?

Do you own any of the following items?

Boat/Yacht

Motorcycle

ATV

Golf Cart

Vacant Land

Business

Boat Information

Number of Watercraft looking to Insure:

Primary Operator

First Last

Years boating experience

Other Operator Information

Name

Date of Birth

Marital Status

Years Experience

List any operator in or outside the household with regular access to insured watercraft more than 12 times per year

Boat #1

HIN #

Year

Make

Model

Boat Value

Include value of permanent/portable boating equipment

Purchase Price

Year Purchased

Propulsion type

Inboard

Outboard

Inboard/Outboard

Jet

Non-powered

Number of engines

Boat Length

Hull material

Total horsepower

Excluding trolling and kicker motors

Maximum Speed

MPH

Enhanced performance modifications

Blowers, superchargers, etc.

Is boat used for racing?

Storage zip code

Where is boat stored?

Do you own a boat trailer?

Value of trailer

Year purchased

Multi-Owner

More than one owner, not in the same household

Boat #1 Coverage Information

Hull Coverage (Comp & Collision)

Hull Deductible (Comp & Collision)

Liability Limits

Roadside Assistance

Uninsured/Underinsured Boater Coverage

Medical Payments Coverage

Fishing Equipment Coverage

Primary Personal Effects Coverage

Boat #2

Year

Make

Model

Boat Value

Include value of permanent/portable boating equipment

Purchase Price

Year Purchased

HIN #

Propulsion type

Inboard

Outboard

Inboard/Outboard

Jet

Non-powered

Number of engines

Boat Length

Hull material

Total horsepower

Excluding trolling and kicker motors

Maximum Speed

MPH

Enhanced performance modifications

Blowers, superchargers, etc.

Is boat used for racing?

Storage zip code

Where is boat stored?

Do you own a boat trailer?

Value of trailer

Year purchased

Multi-Owner

More than one owner, not in the same household

Boat #2 Coverage Information

Hull Coverage (Comp & Collision)

Hull Deductible (Comp & Collision)

Liability Limits

Roadside Assistance

Uninsured/Underinsured Boater Coverage

Medical Payments Coverage

Fishing Equipment Coverage

Primary Personal Effects Coverage

Boat #3

Year

Make

Model

Boat Value

Include value of permanent/portable boating equipment

Purchase Price

Year Purchased

HIN #

Propulsion type

Inboard

Outboard

Inboard/Outboard

Jet

Non-powered

Number of engines

Boat Length

Hull material

Total horsepower

Excluding trolling and kicker motors

Maximum Speed

MPH

Enhanced performance modifications

Blowers, superchargers, etc.

Is boat used for racing?

Storage zip code

Where is boat stored?

Do you own a boat trailer?

Value of trailer

Year purchased

Multi-Owner

More than one owner, not in the same household

Boat #3 Coverage Information

Hull Coverage (Comp & Collision)

Hull Deductible (Comp & Collision)

Liability Limits

Roadside Assistance

Uninsured/Underinsured Boater Coverage

Medical Payments Coverage

Fishing Equipment Coverage

Primary Personal Effects Coverage

Golf Cart

Year

Make

Model

Primary Use

Transportation

Golfing

Fuel Type

Electric

Gas

Recreational Vehicle

RV Type

Travel Trailer

Motor Home

Year

Manufacturer

Model/Series

Body Style

Value of RV

Length of Ownership

Garaging Zip Code

Vehicle Use

< 30 Days

30-150 Days

> 150 Days

Primary Residence

RV (Full Timer)

Yes

Settlement Options

Total Loss Replacement (new RVs up to two model years old)

Actual Cash Value

Agreed Value

Prior RV Insurance

Yes

Physical Damage Deductibles

$250

$500

$1,000

$2,500

Windshield Coverage

Yes

Medical Payments Coverage

$1,000

$2,500

$5,000

$10,000

Liability Limits

Roadside Assistance

Yes

Emergency Expense Coverage

$750 (included with Physical Damage)

$2,000

$7,500 (Full Timer’s only)

Do you want to review your life insurance program?(Required)

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