Mobile Number *
Email Address *
What's Your Education Level? * -->Select High School/GED Some College Associates Degree Bachelors Degree Masters Degree PhD Other
What's Your Martial Status * -->Select Single Married Engaged Common Law Partnership Complicated Divorced Widowed Other
What's Your Living Situation? * -->Select Own Home Own Manufactured Home Own Condo Rent Home Rent Apartment Rent Condo Living With Someone Other
How Many AT-FAULT Accidents Do You Have In The Past 3 Years? * -->Select None 1 2 3+ Unsure
How Many Tickets Do You Have In The Past 3 Years? * -->Select None 1 2 3+ Unsure
List Any Dates Of Accidents or Tickets If You Know Them:
Do You Need An SR-22? * -->Select Yes No What's An SR-22?
Would You Use A Device That Tracks Your Driving To Save On Your Insurance? * -->Select Yes Maybe No
Do You Have Any Homeowners/Renters Insurance Claims? * -->Select Yes No Unsure
If So, Please Provide Dates And Type Of Claim(s):
How Long Have You Been With This Carrier? * -->Select Less Than 6 Months 6 Months to 1 Year 1 - 2 Years 2 - 3 Years 3 - 5 Years Over 5 Years No Current Insurance
How Do They Bill You? * -->Select Monthly Quarterly Every 6 Months Annually Other
How Much Are They Charging You? *
Do You Know Your Current Deductibles? * -->Select Less Than $250 $250 $500 $750 $1,000 $2,000 Unsure
Do You Know Your Current Liability Limits? * -->Select State Minimum 30/60/25 50/100/50 100/300/100 250/500/100 500/500/500 Unsure
Have You Taken Defensive Driving Within 3 Years? * -->Select Yes, and I have the certificate Yes, I'll have to get the certificate Yes, but I don't have the certificate No No, but I can for some savings!
Anyone in The Household Drive For A Rideshare Company Like Uber or Lyft? * -->Select None Uber Lyft Both Other
How Much Are They Charging You? *
Do You Know Your Current Deductibles? * -->Select 1% Wind & Hail - $1,000 All Other Perils 1% Wind & Hail - 1% All Other Perils 2% Wind & Hail - $1,000 All Other Perils 2% Wind & Hail - 1% All Other Perils 2% Wind & Hail - 2% All Other Perils 3% or Higher Unsure
When Was Your Roof Last Replaced? * -->Select 1 Year Ago 2 Years Ago 3 Years Ago 4 Years Ago 5 Years Ago 6 - 10 Years Ago 11 - 15 Years Ago Over 15 Years Ago Unsure I Don't Own My Home
Do or Will You Have A Monitored Alarm System? * -->Select I Have A Monitored Alarm System I Will Be Installing One I Don't Have One How Big Is The Discount?
Do You Have A Pool Or Trampoline? * -->Select Pool Trampoline Both Another Outdoor Activity Risk None of the Above
Do You Have Any Dogs? * -->Select Yes, 1 Yes, 2 Yes, 3+ Yes, and they're considered a high risk breed No
If So, What Year?
How Much Are They Charging You? *
Do You Know Your Current Deductibles? * -->Select $500 $1,000 $1,500 $2,000 Unsure
Do or Will You Have A Monitored Alarm System? * -->Select I Have A Monitored Alarm System I Will Be Installing One I Don't Have One How Big Is The Discount?
Do You Have Any Dogs? * -->Select Yes, 1 Yes, 2 Yes, 3+ Yes, and they're considered a high risk breed No
How Much Are They Charging You? *
Do You Know Your Current Deductibles? * -->Select $500 $1,000 $1,500 $2,000 Unsure
Do or Will You Have A Monitored Alarm System? * -->Select I Have A Monitored Alarm System I Will Be Installing One I Don't Have One How Big Is The Discount?
Do You Have Any Dogs? * -->Select Yes, 1 Yes, 2 Yes, 3+ Yes, and they're considered a high risk breed No
Are You Responsible For "The Walls Inward?" * -->Select Yes No Unsure
How Much Are They Charging You? *
Do You Know Your Current Deductibles? * -->Select 1% Wind & Hail - $1,000 All Other Perils 1% Wind & Hail - 1% All Other Perils 2% Wind & Hail - $1,000 All Other Perils 2% Wind & Hail - 1% All Other Perils 2% Wind & Hail - 2% All Other Perils 3% or Higher Unsure
When Was Your Roof Last Replaced? * -->Select 1 Year Ago 2 Years Ago 3 Years Ago 4 Years Ago 5 Years Ago 6 - 10 Years Ago 11 - 15 Years Ago Over 15 Years Ago Unsure I Don't Own My Home
Do or Will You Have A Monitored Alarm System? * -->Select I Have A Monitored Alarm System I Will Be Installing One I Don't Have One How Big Is The Discount?
Do You Have A Pool Or Trampoline? * -->Select Pool Trampoline Both Another Outdoor Activity Risk None of the Above
Do You Have Any Dogs? * -->Select Yes, 1 Yes, 2 Yes, 3+ Yes, and they're considered a high risk breed No
If So, What Year?
How Long Have You Been With This Carrier? * -->Select Less Than 6 Months 6 Months to 1 Year 1 - 2 Years 2 - 3 Years 3 - 5 Years Over 5 Years No Current Insurance
How Do They Bill You? * -->Select Monthly Quarterly Every 6 Months Annually Other
How Much Are They Charging You? *
Do You Know Your Current Deductibles? * -->Select Less Than $250 $250 $500 $750 $1,000 $2,000 Unsure
Do You Know Your Current Liability Limits? * -->Select State Minimum 30/60/25 50/100/50 100/300/100 250/500/100 500/500/500 Unsure
What's The Value Of The Vehicle(s)? *
Is The Vehicle Fully Restored? * -->Select Yes No No, But Almost Complete No, But The Outside Is Complete No, But The Inside Is Complete
Miles You Plan To Drive It Within A Year: *
Any Additional Info You Think We Need:
Current Motorcycle Insurance Carrier *
How Long Have You Been With This Carrier? * -->Select Less Than 6 Months 6 Months to 1 Year 1 - 2 Years 2 - 3 Years 3 - 5 Years Over 5 Years No Current Insurance
How Do They Bill You? * -->Select Monthly Quarterly Every 6 Months Annually Other
How Much Are They Charging You? *
Do You Know Your Current Deductibles? * -->Select Less Than $250 $250 $500 $750 $1,000 $2,000 Unsure
Do You Know Your Current Liability Limits? * -->Select State Minimum 30/60/25 50/100/50 100/300/100 250/500/100 500/500/500 Unsure
What's The Value Of The Vehicle(s)? *
Motorcycle Endorsement On Your License? * -->Select Yes No In The Process Of Getting It
Miles You Plan To Drive It Within A Year: *
Any Accessories? If So, Include Value $$ *
Any Additional Info You Think We Need:
Current RV Insurance Carrier *
How Long Have You Been With This Carrier? * -->Select Less Than 6 Months 6 Months to 1 Year 1 - 2 Years 2 - 3 Years 3 - 5 Years Over 5 Years No Current Insurance
How Do They Bill You? * -->Select Monthly Quarterly Every 6 Months Annually Other
How Much Are They Charging You? *
Do You Know Your Current Deductibles? * -->Select Less Than $250 $250 $500 $750 $1,000 $2,000 Unsure
Do You Know Your Current Liability Limits? * -->Select State Minimum 30/60/25 50/100/50 100/300/100 250/500/100 500/500/500 Unsure
What's The Value Of The Vehicle(s)? *
Any Accessories? If So, Include Value $$ *
Any Additional Info You Think We Need:
Current Travel Trailer Insurance Carrier *
How Long Have You Been With This Carrier? * -->Select Less Than 6 Months 6 Months to 1 Year 1 - 2 Years 2 - 3 Years 3 - 5 Years Over 5 Years No Current Insurance
How Do They Bill You? * -->Select Monthly Quarterly Every 6 Months Annually Other
How Much Are They Charging You? *
Do You Know Your Current Deductibles? * -->Select Less Than $250 $250 $500 $750 $1,000 $2,000 Unsure
What's The Length Of The Trailer? *
What's The Value Of The Vehicle(s)? *
Any Accessories? If So, Include Value $$ *
Are You Living In It Full-time? * -->Select Yes No
Any Additional Info You Think We Need:
Current Trailer Insurance Carrier *
How Long Have You Been With This Carrier? * -->Select Less Than 6 Months 6 Months to 1 Year 1 - 2 Years 2 - 3 Years 3 - 5 Years Over 5 Years No Current Insurance
How Do They Bill You? * -->Select Monthly Quarterly Every 6 Months Annually Other
How Much Are They Charging You? *
Do You Know Your Current Deductibles? * -->Select Less Than $250 $250 $500 $750 $1,000 $2,000 Unsure
What's The Length Of The Trailer? *
What's The Value Of The Vehicle(s)? *
Any Additional Info You Think We Need:
Current Boat/Sea-Doo Insurance Carrier *
How Long Have You Been With This Carrier? * -->Select Less Than 6 Months 6 Months to 1 Year 1 - 2 Years 2 - 3 Years 3 - 5 Years Over 5 Years No Current Insurance
How Do They Bill You? * -->Select Monthly Quarterly Every 6 Months Annually Other
How Much Are They Charging You? *
Do You Know Your Current Deductibles? * -->Select Less Than $250 $250 $500 $750 $1,000 $2,000 Unsure
What's The Length Of The Boat/Sea-Doo? *
What's The Value Of The Boat(s)/Sea-Doo(s)? *
Any Accessories? If So, Include Value $$ *
Have You Taken A Boater's Safety Course? * -->Select Yes No Yes, but it's not valid anymore
Any Additional Info You Think We Need:
Current Off-Road Vehicle Insurance Carrier *
How Long Have You Been With This Carrier? * -->Select Less Than 6 Months 6 Months to 1 Year 1 - 2 Years 2 - 3 Years 3 - 5 Years Over 5 Years No Current Insurance
How Do They Bill You? * -->Select Monthly Quarterly Every 6 Months Annually Other
How Much Are They Charging You? *
Do You Know Your Current Deductibles? * -->Select Less Than $250 $250 $500 $750 $1,000 $2,000 Unsure
What's The Value Of The Off-Road Vehicle(s)? *
Any Accessories? If So, Include Value $$ *
Any Additional Info You Think We Need:
Current Landlord/Rental Insurance Carrier *
How Long Have You Been With This Carrier? * -->Select Less Than 6 Months 6 Months to 1 Year 1 - 2 Years 2 - 3 Years 3 - 5 Years Over 5 Years No Current Insurance
How Do They Bill You? * -->Select Monthly Quarterly Every 6 Months Annually Other
How Much Are They Charging You? *
Do You Know Your Current Deductibles? * -->Select 1% Wind & Hail - $1,000 All Other Perils 1% Wind & Hail - 1% All Other Perils 2% Wind & Hail - $1,000 All Other Perils 2% Wind & Hail - 1% All Other Perils 2% Wind & Hail - 2% All Other Perils 3% or Higher Unsure
What's The Value Of The Landlord/Rental? *
Do You Rent This Property As Short-Term Rental? (AirBNB, etc.) * -->Select Yes, all the time Yes, half the year No, but I'm looking at it in the future No
Do You Use A Property Management Company? * Yes No Unsure
Do You Supply Any Personal Property? (Washer, Dryer, Fridge, etc.) * -->Select Yes No
What Year Was The Roof Last Replaced? *
Any Additional Info You Think We Need:
Do You Currently Have An Umbrella Policy In Force? * -->Select Yes No Unsure
If So, How Much Is The Limit? -->Select $1,000,000 $2,000,000 $5,000,000 More than $5,000,000
How Much $$ In Assets Do You Need To Protect? * -->Select Under $1,000,000 $1,000,000 to $2,000,000 $2,000,000 to $3,000,000 $3,000,000 to $4,000,000 $4,000,000 to $5,000,000 Over $5,000,000
Any Additional Info?
