Please note that all fields followed by an asterisk must be filled in. First Name*
First Name*
Last Name*
Last Name*
E-mail Address*
E-mail Address*
Street Address*
Street Address*
City*
City*
State/Prov*
State/Prov*
Zip/Postal Code*
Zip/Postal Code*
Home Phone Business Phone Fax Cell Phone How did you hear about our Agency?*
How did you hear about our Agency?*
---Select--- \nReferred
Current customer
Online search engine
Online quote site
Yellow Pages
Insurance company site
Other
If other, please list. Date of Birth (mm/dd/yyyy)*
Date of Birth (mm/dd/yyyy)*
Sex*
Sex*
---Select--- \nFemale
Male
Marital Status*
Marital Status*
---Select--- \nSingle
Married
Separated
Divorced
Widowed
Occupation*
Occupation*
Highest Level of Education
---Select--- \nLess than High School
High School
Some College
Community College
Bachelors Degree
Masters Degree
Ph. D.
Medical Degree
Law Degree
Social Security Number Self Credit Rating
---Select--- \nExcellent
Good
Fair
Poor
Not Sure
Best way to be contacted
---Select--- \nEmail
Home Phone
Business Phone
Cell Phone
When would you like to be contacted?
---Select--- \nImmediately
Within 48hrs
Within a week
Best Time to Call
---Select--- \n8am-10am
10am-Noon
Noon-1pm
1-3pm
3-5pm
5-7pm
7-9pm
Do you currently have insurance?*
Do you currently have insurance?*
---Select--- \nYes
No
Current Insurance Company Date Current Policy Expires Property address, if different. Is this a new purchase?
---Select--- \nYes
No
Year Purchased/Closing Date*
Year Purchased/Closing Date*
Purchased Price/Sales Price*
Purchased Price/Sales Price*
Loan Amount Coverage amount desired.*
Coverage amount desired.*
Deductible Desired.*
Deductible Desired.*
---Select--- \n$500
$1,000
$2,500
Will this be your primary residence?*
Will this be your primary residence?*
---Select--- \nYes
No
If not, what type of residence?
---Select--- \nSecondary Residence
Rental Property
Vacant with plans to rent.
Vacant with plans to sell.
Year of Home*
Year of Home*
If > 20 years old, Please list all updates and year completed. Age of Roof? Square Footage*
Square Footage*
Construction (Brick,Frame, Vinyl, etc.)*
Construction (Brick,Frame, Vinyl, etc.)*
Is home within 1000 feet of a fire hydrant?*
Is home within 1000 feet of a fire hydrant?*
---Select--- \nYes
No
Is home located within 5 miles of a fire station?*
Is home located within 5 miles of a fire station?*
---Select--- \nYes
No
Is home at risk for flooding or high water?*
Is home at risk for flooding or high water?*
---Select--- \nYes
No
Is home located within brush hazard?*
Is home located within brush hazard?*
---Select--- \nYes
No
Do you own a dog?*
Do you own a dog?*
---Select--- \nYes
No
If yes, how many and what breed? If yes, any bite history?
---Select--- \nYes
No
Do you have a swimming pool?*
Do you have a swimming pool?*
---Select--- \nYes
No
If yes, is it fenced?
---Select--- \nYes
No
If yes, is there a diving board?
---Select--- \nYes
No
Do you have a trampoline?*
Do you have a trampoline?*
---Select--- \nYes
No
Have you had any losses or filed any claims in the last 5 years?*
Have you had any losses or filed any claims in the last 5 years?*
---Select--- \nYes
No
If yes, list dates and type of claim. Anyone in the house a smoker?*
Anyone in the house a smoker?*
---Select--- \nYes
No
Does the home have a monitored alarm system?*
Does the home have a monitored alarm system?*
---Select--- \nYes
No
Is there a business on the premises?*
Is there a business on the premises?*
---Select--- \nYes
No
Interested in auto quotes as well?
---Select--- \nYes
No
