New Vehicle Purchase New Vehicle Purchase Your Name Street Address Your Email Are you adding or replacing a vehicle? addingreplacing If replacing, which vehicle is being replaced? VIN of new vehicle Vehicle purchase/trade date What is the primary use for the new vehicle? commuting to work/schoolpleasure useused for business What type of business? Who is/will the vehicle registered to? Who will be the primary driver of this vehicle? Are you financing or leasing the new vehicle? financingleasingno, I own it! Please list the name and address of the bank associated with the loan or lease. If it's financed or leased, would you like gap coverage? (this covers the loan amount if the vehicle is totaled and you owe more than it's worth) yesno What coverage would you like on the new vehicle? (If financed or leased, you'll need to carry both comprehensive & collision) liability onlycomprehensive (no collision)comprehensive & collisionsame as vehicle being replacednot sure (call me) Select all that apply (if any). This vehicle: has existing damagehas salvaged titlehas customized equipmentis garaged elsewhere Are there any other changes you need to make at this time? yesno Please explain What is the total number of vehicles in your household including newly-purchased one? 12345 If needed, attach file here (10Mb limit- jpg/jpeg/gif/png/doc/csv/pdf/xls files accepted) I understand this is not a legal form and the act of submitting this form does not guarantee or bind coverage in any way. We will confirm with you that we received this information and begin processing it. If you have not heard back from us within 24 hours, please call us at 317-852-8330. Check this box to agree to these terms Umbrella Risk Calculator Umbrella Risk Calculator Home & Auto Renewal Survey Home & Auto Renewal Survey Your name Street address Your preferred email Best phone number to reach you Please indicate your current marital status. singlemarriedengageddivorcedwidowed Spouse's first and last name Best phone number for spouse. Email address for spouse. Home Questions Since your last review... Has anyone moved in or out of the household in the last 12 months? *students away at college are still considered household members yesno If so, please explain Have you installed a (third-party) monitored security or fire alarm system in the past 12 months? yesno burglary onlyburglary and firefire only Do you, or another household member, work from home? yesno Are there any business operations conducted in the home? daycare, music lessons, hairstylist, etc.. yesno Please provide more detail What is the estimated value of your personal property at your residence that you use for work? ex: computer, laptop, desk, furniture, filing cabinets, etc Have you made any significant home improvements?* *wiring, HVAC, plumbing, roof, additions, etc... yesno Please provide more details: Have you purchased any other properties? *rentals, secondary or seasonal home nonerentalsecondary/seasonal Have you purchased any of the following or similar items? nonewatercraftmotorcyclesnowmobileRVATV Have you acquired any pets or livestock? yesno Please provide more detail (type, breed, count) : Have you installed any of the following or similar items? nonepooljacuzzitrampolinefree standing wood stove Have you acquired any valuable collections? *artwork, jewelry, furs, precious metals or guns, etc... yesno Please provide more details: Are you satisfied with your current deductible? yesnocontact me with options Your insurance company has additional coverage options for home you might be interested in. (select your company below and choose the coverage(s) you would like more info about) —Please choose an option—ErieAAAGrangeTravelersProgressive/ASISafeCoStillwaterOhio MutualOpenly sewer or drain backupextended water (flood)earthquakemine subsidence/sinkholewatercraft liabilityfarm equipmentfarm liabilityfarm livestockfarm propertyfarm operationsburied utility lineequipment breakdownidentity recovery/fraudnot interested sewer or drain backupearthquakeAAA membershipnot interested sewer or drain backupearthquakesinkholeequipment breakdownassisted living carehome cyber protectionburied utility lineidentity theftfarming liabilitynot interested sewer or drain backupearthquakeequipment breakdownidentity fraud expensedecreasing deductibleloss forgivenesspersonal injuryroof & siding matchingfarming liabilitywater seepage/leakageburied utility lineassisted living carenot interested sewer or drain backupearthquakemine subsidencegolf cart coveragehome computer coverageidentity managementnot interested sewer or drain backupearthquakehome day carefarming liabilityroof & siding matchingburied utility lineidentity theft recoverypersonal offenseequipment breakdownhome warrantypet health insurancenot interested sewer or drain backupearthquakeidentity recoveryhome systems protectioncyber/data breach/bullypersonal injurynot interested sewer or drain backupearthquakeequipment breakdownfarming liabilityburied utility linehome daycareassisted living carenot interested sewer or drain backupearthquakeequipment breakdownburied utility linehome-sharingsupplemental boat hull coveragecyber/identity theftnot interested Do you currently have a mortgage on your home? yesno We need to make sure we have the correct mortgage company listed on your policy. Please provide bank's name. Auto Questions Since your last review... Are there any newly-licensed drivers or any drivers no longer in household? yesno Please provide more details: Has a student moved away to college (100+ road miles) without the use of a vehicle? yesno Have you, or any driver, changed job or school locations or work from home? yesno Please explain: Does any household driver participate in any ridesharing activities? (Uber/Lyft driver, Door Dash, UberEats,etc) yesno Please let us know which vehicle(s) are used Have any insured vehicles been customized or altered? yesno Please provide more details: Have you paid off any vehicle loans this past year? yesno Which loan(s) are paid off? What is the total number of vehicles registered to you and/or your spouse/significant other? (REMEMBER- you should not insure vehicles not registered to you/mate.) Have you considered increasing your liability limits for better protection of your assets? yes, more info pleaseno thanks Your insurance company has additional coverage options for auto you might be interested in. (select your company below and choose the coverage(s) you would like more info about) —Please choose an option—ErieAAAGrangeTravelersProgressiveSafeCoStillwaterOhio Mutual comprehensivefull glass $0 deductiblecollisionroadside serviceloss of use (rental car)new auto securityrideshare gap (Uber/Lyft)rate lockauto plus (dim. deductibles)not interested comprehensivefull glass $0 deductiblecollisionroadside assistanceloss of use (rental car)special equipmentloan/lease gap coveragenot interested comprehensivefull glass $0 deductiblecollisionroadsideloss of use (rental car)ID theftpet injurymobile devicesnew auto replacedeductible waiverloan/lease gapcustom equipmentrideshare gapminor violation forgiveaccident forgivenessnot interested comprehensive$50 glass deductiblecollisionroadsideloss of use (rental)loan/lease gapincreased custom equiplimited mexico coverageRDP accident/viol forgivePRDP (+dim deducts)new car replacementIntelliDrive savingsnot interested comprehensivefull glass $0 deductiblecollisionroadsideloss of use (rental)loan payoffincreased custom equipSnapShot savingsdiminishing deductiblespaperless discountnot interested comprehensivefull glass $0 deductiblecollisionroadsideloss of use (rental)accident forgivenessworld-wide rentalloan lease/gapnew vehicle replacementcustom equipemergency assistancerideshare (Uber/Lyft)claims free cash backnot interested full glass $0 deductiblenot interested full glass $0 deductibleenhanced collisionroadsidetrip interruptionloan/lease gapaccident forgivenesspet injurynot interested With regards to life insurance, select all that apply to you. I/spouse have w/ employerinterested in optionsI don't have anynot interestedI have but want to review it How would you rate our service to you? below averageaverageabove averagesuperior Are there any areas you feel we could improve upon in providing service to you? noyes We welcome your feedback... Share this link with a friend to be automatically entered into our referral program where you can win gift cards and CASH! The more you refer, the more likely you'll win! https://wi-insure.com/referrals/ Please consider leaving us a review here: (link opens new window) Leave us a review Homeowner's Renewal Survey Homeowner's Renewal Survey Error: Contact form not found. Auto Renewal Survey Auto Renewal Survey Your name Street address Your preferred email Best phone number to reach you Please indicate your current marital status. singlemarrieddivorcedwidowed Spouse's first and last name Best phone number for spouse. Email address for spouse. Auto Questions Since your last review... Are there any newly-licensed drivers or any drivers no longer in household? yesno Has a student moved away to college (100+ road miles) without the use of a vehicle? yesno Have you, or any driver, changed job or school locations or work from home? yesno Please provide more details: Does any household driver participate in any ridesharing activities? (Uber/Lyft driver, Door Dash, UberEats,etc) yesno Please let us know which vehicle(s) are used Have any insured vehicles been customized or altered? yesno Please provide more details: Have you paid off any vehicle loans this past year? yesno Which loan(s) are paid off? What is the total number of vehicles registered to you and/or your spouse/significant other? (REMEMBER- you should not insure vehicles not registered to you/mate.) Would you be interested in bundling your homeowner's or renter's insurance with your auto? multi-policy discounts can save you up to 40%! yesI already dono Have you considered increasing your liability limits for better protection of your assets? yes, more info pleaseno thanks Your insurance company has additional coverage options for auto you might be interested in. (select your company below and choose the coverage(s) you would like more info about) —Please choose an option—ErieAAAGrangeTravelersProgressiveSafeCoStillwaterOhio Mutual comprehensivefull glass $0 deductiblecollisionroadside serviceloss of use (rental car)new auto securityrideshare gap (Uber/Lyft)rate lockauto plus (dim. deductibles)not interested comprehensivefull glass $0 deductiblecollisionroadside assistanceloss of use (rental car)special equipmentloan/lease gap coveragenot interested comprehensivefull glass $0 deductiblecollisionroadsideloss of use (rental car)ID theftpet injurymobile devicesnew auto replacedeductible waiverloan/lease gapcustom equipmentrideshare gapminor violation forgiveaccident forgivenessnot interested comprehensive$50 glass deductiblecollisionroadsideloss of use (rental)loan/lease gapincreased custom equiplimited mexico coverageRDP accident/viol forgivePRDP (+dim deducts)new car replacementIntelliDrive savingsnot interested comprehensivefull glass $0 deductiblecollisionroadsideloss of use (rental)loan payoffincreased custom equipSnapShot savingsdiminishing deductiblespaperless discountnot interested comprehensivefull glass $0 deductiblecollisionroadsideloss of use (rental)accident forgivenessworld-wide rentalloan/lease gapnew vehicle replacementcustom equipemergency assistancerideshare (Uber/Lyft)claims free cash backnot interested full glass $0 deductiblenot interested full glass $0 deductibleenhanced collisionroadsidetrip interruptionloan/lease gapaccident forgivenesspet injurynot interested With regards to life insurance, select all that apply to you. I/spouse have w/ employerinterested in optionsI don't have anynot interestedI have but want to review it How would you rate our service to you? below averageaverageabove averagesuperior Are there any areas you feel we could improve upon in providing service to you? noyes We welcome your feedback... Share this link with a friend to be automatically entered into our referral program where you can win gift cards and CASH! The more you refer, the more likely you'll win! https://wi-insure.com/referrals/ Please consider leaving us a review here: (link opens new window) Leave us a review