Do you have a proposed closing date?
yesno

What is your primary reason for shopping your insurance at this time?

We recommend quoting home/condo/renter’s WITH the auto to avoid losing major discounts!

IMPORTANT — To qualify for an umbrella, we have to also insure all your autos too!

We recommend having your primary home (and auto) quoted along with your rental home for most discounts.

Your driver’s license state

Your driver’s license number (not required for quote but helps for accuracy)

Have you had any accidents or tickets the past 5 years?
yesno

Do you need an SR-22 filing?
yesno

Are you a driver for any motorcycle?
yesno

Your spouse’s full name (legal)

Your spouse’s date of birth

Your spouse’s social security number (not required for quote but helps for accuracy)

What is your spouse’s primary occupation? (possible discounts with some companies)

NOTE: your spouse will be referred to as “co-applicant” throughout form.

Yes, I have a domestic partner with a financial interest in products being quoted.

What was your previous permanent address?

—–Homeowner’s Section—–

Property Information

Is this a new purchase or are we quoting your current home?
new purchasecurrent home

This residence is:
my primary homea secondary/seasonal homeother

What year was the home built?

What is the finished square footage of this home? (do not include finished basement or attic)

How many stories is the home? (do not include basement)
—Please choose an option—1 story1-1/2 story2 story2-1/2 story3 storyBi-levelTri-level

How many full bathrooms are there?

How many half bathrooms are there?

How would you classify the quality level of the kitchen?
builder’s grade | semi-custom | custom
builder's gradesemi-customcustom

How would you classify the quality level of the bathroom(s)?
builder’s grade | semi-custom | custom
builder's gradesemi-customcustom

Is there a garage?
attacheddetachedno garage

Are there any other detached structures on the premises?
yesno

What is the exterior finish of the home? (check all that apply)
brickvinyl sidingwood sidinghardie plank sidingstonealuminum sidingshakesstucco

What type of foundation does the home have? (check all that apply)
slabcrawlspacebasementbasement- walkout

Are there any auxiliary heat sources in the home? (check all that apply)
nonewood burning fireplacemulti-sided fireplacegas fireplacefree-standing wood stove

How old (years) is the roof on the home?

What is the roofing material?
architectural (3D) shinglesflat 3-tab shinglemetalother

What type of central heating system is in the home?
electricgasheat pumpgeothermal

What is the age (years) of the heating system?

Liability Information

How many household residents? (any who would consider this their primary residence.)

Is there, or will there be, a trampoline?
yesno

Is there a swimming pool?
yesno

Pets, animals or livestock. Check any box that applies to you.
no pets/animalsdog(s)farm/livestockexotic animal(s)

Do any of the following apply to you/your household?: (check all the apply)
I/spouse work from homeour home is rented (ex. AirBnb)have business in homenone

Property Losses/Claims History Information

In the past 5 years, have you filed any claims on any homeowner’s or renter’s policies?
yesno

Coverage Information

The standard minimum homeowner’s deductible for property losses is $1,000.
check for higher deductible

Please select the desired limit for personal liability coverage. (this protects you and household family members against bodily injury/property damage for which you’re found legally liable)
—Please choose an option—$300,000 ea occurrence$500,000 ea occurrenceI'm interested in more

Please let us know if you’d be interested in, or would like more info about the following coverages
nonesewer or drain backupburied utility line coverageequipment breakdownearthquakeidentity theft recoverypersonal injuryroof & siding matchingvaluable jewelry

What date would you like this policy to begin

How is your homeowner’s insurance currently paid?
billed to mortgageself pay, no mortgageself pay, have mortgage

—–Condo-owner’s Section—–

Property Information

Is this a new purchase or are we quoting your current home?
new purchasecurrent home

This residence is:
my primary homea secondary/seasonal homeother

What year was the condo built?

What is the finished square footage of this home? (do not include finished basement or attic)

How many stories is the condo? (do not include basement)
—Please choose an option—1 story1-1/2 story2 story2-1/2 story3 story

How many full bathrooms are there?

How many half bathrooms are there?

How would you classify the quality level of the kitchen?
builder’s grade | semi-custom | custom
builder's gradesemi-customcustom

How would you classify the quality level of the bathroom(s)?
builder’s grade | semi-custom | custom
builder's gradesemi-customcustom

Is there a garage?
attacheddetachedno garage

What type of foundation does the home have? (check all that apply)
slabcrawlspacebasementbasement- walkout

Are there any auxiliary heat sources in the home? (check all that apply)
nonewood burning fireplacemulti-sided fireplacegas fireplacefree-standing wood stove

How old (years) is the roof on the home?

What type of central heating system is in the home?
electricgasheat pumpgeothermal

What is the age (years) of the heating system?

What type of electrical service does this home have?
circuit breakersfusesknob & tube wiring

Liability Information

How many household residents? (any who would consider this their primary residence.)

Is there, or will there be, a trampoline?
yesno

Is there a swimming pool?
yesno

Pets, animals or livestock. Check any box that applies to you.
no pets/animalsdog(s)farm/livestockexotic animal(s)

Is there any type of business operation in the home (ex. in-home daycare or one that generates higher than normal foot traffic)
yesno

Property Losses/Claims History Information

In the past 5 years, have you filed any claims on any homeowner’s or renter’s policies?
yesno

Coverage Information

The standard condo-owner’s deductible we usually quote is $500.
check for higher deductible

Please let us know if you’d be interested in, or would like more info about the following coverages
nonesewer or drain backupearthquakeidentity theft recoverypersonal injuryvaluable jewelry

What date would you like this policy to begin?

How is your condo insurance currently paid?
billed to mortgageI pay myself

—–Rental Section—–

Property Information

How many rental properties do you own? (max. 2 for this form)

Rental #1 Info

Is this a new purchase or a rental you currently own?
new purchasecurrently own

What is the address of the rental property?

What year was the home built?

What is the finished square footage of this home? (do not include finished basement or attic)

How many stories is the home? (do not include basement)
—Please choose an option—1 story1-1/2 story2 story2-1/2 story3 storyBi-levelTri-level

How many full bathrooms are there?

How many half bathrooms are there?

How would you classify the quality level of the kitchen?
builder’s grade | semi-custom | custom
builder's gradesemi-customcustom

How would you classify the quality level of the bathroom(s)?
builder’s grade | semi-custom | custom
builder's gradesemi-customcustom

Is there a garage?
attacheddetachedno garage

Are there any other detached structures on the premises?
yesno

What is the exterior finish of the home? (check all that apply)
brickvinyl sidingwood sidinghardie plank sidingstonealuminum sidingshakesstucco

What type of foundation does the home have? (check all that apply)
slabcrawlspacebasementbasement- walkout

Are there any auxiliary heat sources in the home? (check all that apply)
nonewood burning fireplacemulti-sided fireplacegas fireplacefree-standing wood stove

How old (years) is the roof on the home?

What is the roofing material?
architectural (3D) shinglesflat 3-tab shinglemetalother

What type of central heating system is in the home?
electricgasheat pumpgeothermal

What is the age (years) of the heating system?

What type of electrical service does this home have?
circuit breakersfusesknob & tube wiring

Is this rental currently tenant-occupied, or will be in the next 30 days?
yesno

Is the rental undergoing any renovations?
yesno

Are lease agreements annual or short-term basis?
annualshort-term

Liability Information

Is there, or will there be, a trampoline?
yesno

Is there a swimming pool?
yesno

Pets, animals or livestock. Check any box that applies to your tenant(s).
no pets/animalsdog(s)farm/livestockexotic animal(s)

Does your tenant have any type of business operation in the home (ex. in-home daycare or one that generates higher than normal foot traffic)
yesno

Property Losses/Claims History Information

In the past 5 years, have you filed any claims on any homeowner’s, landlord or renter’s policies?
yesno

Coverage Information

The standard minimum homeowner’s deductible we usually quote is $1,000.
check for higher deductible

Please let us know if you’d be interested in, or would like more info about the following coverages
nonesewer or drain backupequipment breakdownearthquakeroof & siding matching

What date would you like this policy to begin

—–Renter’s Section—–

Property Information

What is the address of the new property you’re renting?

Coverage Information

How much personal property coverage would you like? (minimum is $20,000)

Please choose a deductible
$250$500$1.000

Please let us know if you’d be interested in, or would like more info about the following coverages
nonesewer or drain backupearthquakeidentity theft recoverypersonal injuryvaluable jewelry

Liability Information

How many household residents? (any who would consider this their primary residence.)

If you’d like to provide additional information (optional):

Is there, or will there be, a trampoline?
yesno

Is there a swimming pool?
yesno

Pets, animals or livestock. Check any box that applies to you.
no pets/animalsdog(s)farm/livestockexotic animal(s)

Is there any type of business operation in the home/apartment? (ex. in-home daycare or one that generates higher than normal foot traffic)
yesno

Please choose an amount for personal liability coverage
$300,000$500,000

Property Losses/Claims History Information

In the past 5 years, have you filed any claims on any homeowner’s or renter’s policies?
yesno

What date would you like this policy to begin

Driver Information

You’ve already entered driver information for yourself (and possibly co-applicant).

How many other licensed drivers live in the same household (even if they don’t drive your car(s))? (max. 6 for this form)
0123456

Liability Limits

Liability limits are available in two formats, Split & Combined limits.

–Split Limits provide separate limits for bodily injury & property damage
(ex. bodily injury $100,000 ea person/ $300,000 per acc./ property damage $100,000 per acc.)

–Combined Single Limit (CSL) provides one single limit for bodily injury & property damage.
(ex. $300,000 ea acc. CSL bodily injury & property damage combined)

Select the liability limits for Bodily Injury to Others*
$100,000/$300,000$250,000/$500,000$300,000 CSL$500,000 CSLother amount

* We will apply these same limits to the Un-Insured/Under-Insured Motorist Bodily Injury & Property Damage Coverage

Select the limit for Medical Payments (per person/ for you and your passengers)
$5,000$10,000$25,000$100,000

—–Auto Section—–

Current Coverage

Do you currently have auto insurance?
yesno

How do you currently pay your auto insurance premium?
monthlyquarterly6 mo. full pay12 mo. full pay

Would you (& other listed drivers) be interested in participating in any programs offered by companies to reward safe driving habits with discounts based on driving performance? (most are now smartphone app-based programs lasting about 90 days with possible final discounts up to 20-30%)
yes, please quoteno

Vehicle Information

How many vehicles do you have registered to you and/or co-applicant? Do not include RV’s. There’s a separate section for Rv’s (max. 6 for this form)
It is not recommended to insure your vehicles with multiple companies; please list all here.
123456

Vehicle 1 Info

Enter VIN for Vehicle 1 (optional)

Enter year, make & model

Is this vehicle financed or leased?
financedleasedpaid off

Did you buy this vehicle new or used?
newused

Who is the vehicle registered to?

Check any boxes that apply to this vehicle
clean titlesalvaged titlejunk titlerebuilt title

How is this vehicle primarily used?
commutingpleasurebusinessless than 8k mi/yr

Do you wish to carry physical damage coverage on this vehicle? (required if financed or leased)
yesno, liability onlyplease quote with/without

What date would you like this policy to begin?

—–Motorcycle Section—–

How many motorcycles are registered to you and/or co-applicant? (max. 4 for this form)
1234

Motorcycle 1 Info

Enter VIN for Motorcycle 1 (optional)

Enter year, make & model

Is this vehicle a trike?
yesno

What size is the engine (cc’s)?

Is there a modified frame, turbo/nitrous kit, snorkel or lift kit?
yesno

Does this motorcycle have anti-lock brakes?
yesno

What is the current estimated value?

Is this motorcycle financed?
yesno

Did you buy this motorycle new or used?
newused

Who is the motorcycle registered to?

Do you wish to carry physical damage coverage on this motorcycle? (required if financed)
yesno, liability onlyplease quote with/without

—–Watercraft Section—–

How many watercraft are registered to you and/or co-applicant? (max. 2 for this form)
12

Watercraft 1 Info

What is the hull ID number? (optional– required only for policy issue)

Enter year, make & model

What is the hull length (feet)?

What is the hull material?
fiberglassaluminuminflatable

How many motors does this watercraft have?
1234none

What is the motor’s year and make?

What is the total horsepower?

What type of propulsion? more info
—Please choose an option—outboardinboard/outboardinboardjetsailboat/non-powered

Has the engine been modified to enhance performance?
yesno

What is the watercraft’s maximum speed?

What is the current market value of the boat (including motor)?

What year did you purchase this watercraft?

Are you the original owner of this watercraft?
yesno

Is the watercraft usually kept at your residence during boating season?
yesno

During the winter months, what is the zip code of the location where watercraft is stored?

Select all that apply to use of the watercraft:
pleasure use exclusivelyracing/speed contestsbusiness/commercial userented/leased to otherslive on-board

Do you wish to carry physical damage coverage on this watercraft (and trailer)? (required if financed)
yesno, liability only

—–Travel Trailer Section—–

Travel Trailer Year
202120202019201820172016201520142013201220102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985

Travel Trailer Make

Travel Trailer Model

Travel Trailer VIN (17 characters)

Length of travel trailer (ft.)

Number of slide outs?

How is travel trailer towed?
bumper hitchbed hitch

Date of purchase (best estimate if unknown)

Are you the original owner?
yesno

Current value of travel trailer

Garaging Zip Code

Is travel trailer parked at a single location year round?
yesno

Is the travel trailer a rented vehicle, ever rented to others, or used for business?
yesno

Is the travel trailer taken to/from work or used at a work location?
yesno

Primary vehicle use
recreation useit's my primary residence

What is the approximate number of days used per year?

Is the travel trailer financed?
yesno

Years of experience operating a travel trailer (in years. Enter 0 if none)

Liability coverage is extended from the towing vehicle.

Physical damage options:

Select Comprehensive deductible
$250$500$750$1,000$2,500$5,000
I want Collision

Additional vacation liability (includes $10,000)
yesno

Personal Effects (round to nearest thousand dollars. Enter ‘0’ if none)

Roadside Coverage
yesno

—–Motorhome Section—–

Enter VIN for motorhome (optional)

Enter year, make & model

Length of motorhome (ft.)

Number of slide outs?

Motorhome purchase year

Are you the original owner?
yesno

Current value of motorhome

Garaging zip code

Is motorhome a rented vehicle, ever rented to others or used for business?
yesno

Is motorhome take to/from work or used at a work location?
yesno

Is this motorhome your only household vehicle registered for street use?
yesno

Primary motorhome use:
recreation useit's my primary residence

Enter the number of days this motorhome is used per year (approx.)

Is the motorhome financed?
yesno

Do you wish to carry physical damage coverage on this motorhome? (required if financed)
yesno, liability onlyplease quote with/without

—–Umbrella Section—–

NOTE: We must insure your autos to be able to offer an umbrella

Select the limit of liability for the umbrella:
—Please choose an option—$1,000,000$2,000,000$3,000,000$4,000,000$5,000,000

Would you like the umbrella to include excess Un-insured Motorist protection to you?
yesnoplease quote with/without

Do you, or any household member, own an animal that is vicious or has previously bitten anyone?
yesno

Have you had an umbrella policy canceled, declined or non-renewed in the past 5 years?
yesno

Any liability claims or lawsuits (other than auto) against you or other household member in the past 5 years?
yesno

Is there any business occurring on the premises, including farming, home-sharing, or daycare?
yesno

Is there an unfenced inground swimming pool?
yesno

Are you, or any household member, a professional athlete, actor, celebrity or public figure of any kind?
yesno

Do you, or any household member, hold a director or officer level position with a volunteer, civic or charitable organization?
yesno

Any aircraft owned, leased, chartered or furnished for regular use?
yesno

Number of owned powered watercraft (Enter 0 if none)

Number of company-owned vehicles (Enter 0 if none)

Number of rental properties owned (Enter 0 if none)

Number of secondary/seasonal residences occupied by you (Enter 0 if none)

Number of ATV/motorcycles owned (Enter 0 if none)

Number of classic, antique or motorhomes owned (Enter 0 if none)

—–Flood Section—–

—–Life Section—–

What type of life insurance are you interested in?
termwholefinal expensenot sure

What is the primary reason you’re looking for life insurance S(select all that apply)
temporary needs (debts, tuition, income loss)wealth transfer/estate planningpermanent lifelong coveragefinal expense (max $25k)other

How much protection do you need? (consider total debt, 5-10 yrs of income, weddings/college for kids)

How long would you like the coverage to last?
10 years20 years25 years30 yearspermanently until death

What state were you born in?

What is your height?

What is your weight?

Select all tobacco products you have ever used in the past (check all that apply)
cigarettescigarsmarijuanavaping productsnone

Have you lost a parent, sibling, or child to cancer or heart issues who was younger than 60 years old?
yesno

Do you take medication for high blood pressure?
yesno

Do you take medication for high cholesterol?
yesno

List any medications you are currently taking (if any)

Do you have any health problems or family medical history?
yesno

Who referred you? (We have a referral program and would like to thank the person who referred you!)

Please explain

Please Note: after submitting, you will directed to a secure portal to share your current coverages with us. This will allow us to do a more accurate and thorough job in providing quotes to you.