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Homeowners

Your Information

Your Name:*

Address:*

City:*

State:*

Zip Code:*

Phone:*

Best time to call:

Your Email:*

Occupation:*

Current Homeowners Insurance Information

Company name (not agency):

Policy Expiration Date:

Premium Amount: $

Amount Insured For: $

Policy Type:

Term:

Other:

Home Information

How long at present address:*

Year built:*

Sq. Footage(Excluding garage and basement):*

Claims in the last three years:*

Structure Information

Type:*

Construction:*

Roof:*

Age of roof:* (in years)

Foundation:*

Garage:*

Features

Bathrooms*

# of Full:
# of Half:

Basement:*


Sq. Ft.:*

Deck/Porch/Patio:*
Deck Sq. Ft.:
Porch Sq. Ft.:
Screened Patio Sq.:

Fireplaces*
# of Chimneys:
# of Hearths:

Additional Features

Heating System:*

Central Air:*

Central Vac:*

Security Alarm:*

Fire Alarm:*

Smoke Detector:*

Additional Comments

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Business Insurance

Your Information

Your Name:*

Personal Address:*

City:*

State:*

Zip Code:*

Personal Phone:*

Your Email:*

Business Information

Business Name:*

Business-Address:*

City:*

State:*

Zip Code:*

Business Phone:*

Fax:

Property Questions

Age of building/Year Built:*

Type of building construction:*

Number of stories:*

Other occupancies:

Square feet you occupy:
sq. ft.

Protective Devices

Burglar Alarm

Central Station or local alarm?

Is the building sprinkled?

Business Personal Property

Building:* $

Contents (equipment, inventory, supplies, etc.):* $

General Liability Unit:*

Non-owned and Hired Automobile Liability:* $

Is liquor liability needed?*

Please list other coverages you may need:

Previous Insurance

Please provide information on previous insurance carrier:

Previous Insurance Carrier:

Policy Number:

Prior premium (Annual):

Policy renewal date:

Please provide information about your business:

Years in business:

Projected Gross annual receipts: $

Projected annual payroll: $

Describe your business, product or service

Additional Comments:

Please give any additional comments you feel appropriate for this quote. If you have additional information where there was not enough fields above, please enter them here.

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Commercial Auto

General Information

Your Name:*

Address:*

City:*

State:*

Zip Code:*

Phone:*

Fax:

E-mail:*

Coverage Information

Liability Amount (csl):*

Uninsured Motorist - Bodily Injury (csl):*

Uninsured Motorist - Property Damage(csl):

Medical:

Hired Auto:

Non-Owned Auto:

Comprehensive Deductible:

Collision Deductible:

Vehicle Information

Total number of vehicles:*

Please enter information for the first and second vehicles below.

Auto #1

Year

Make

Model

VIN #

Gross Vehicle Weight - lbs.

Cost New

Radius (in miles, one way)

Vehicle Use

Please describe in detail what the vehicle is used for:

If commodity is hauled, please explain::

Auto #2

Year

Make

Model

VIN #

Gross Vehicle Weight - lbs.

Cost New

Radius (in miles, one way)

Vehicle Use

Please describe in detail what the vehicle is used for:

If commodity is hauled, please explain:

How many losses have there been in the last 3 years?

(If any, please explain below)

Additional Comments

Please give any additional comments you feel appropriate for this quote. If you have additional information where there was not enough fields above, please enter them here.

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Renters Insurance

Personal Information

Name:*

Address:*

City:*

State:*

Zip:*

Property Address (if different from above):

City:

State:

Zip:

Day Phone:*

Night Phone:

Best Time to Call:
 AM PM

Email Address:*

Occupation:

How Long at Current Job: (years)

Date of Birth:

Smoker:

 Yes No

Current Renters Insurance Information

Company name (not agency):

Policy Expiration Date:

Premium Amount: $

Amount Insured For: $

Policy Type:

Term:

Have you filed any property claims in the past 3 years? if "YES", please give us claim detail below:

 Yes No

Dwelling Information

Living area Sq Ft:

Number of units in your building:

Year Built:

Copper Pluming?
 Yes No

Circuit Breakers?
 Yes No

Alarm System:
 Yes No

Is the home/apartment equipped with at least one working smoke alarm?
 Yes No

Does your home/apartment have at least one fire extinguisher that is 21/2 lbs. or larger?
 Yes No

Do all exterior doors have deadbolt type locks?
 Yes No

Desired Coverages

Deductible:

Comprehensive Personal Liability:

Value of your Contents: $

List any additional Coverage requirements below:

Additional Comments

Please give additional comments you feel appropriate for this question. If you have additional information where there was not enough space, please enter them here:

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Workers Compensation

General Information

Name of Business:*

Contact Name:*

Address:*

City:*

State:*

Zip Code:*

Business Status:*

Other:

Business Tax ID Number:*

Business Phone:*

Fax:

Best Time To Call:
 AM PM

Contact Email Address:*

Current Insurance Information

Company Name (not agency):

Policy Expiration Date:

Premium Amount (Annual): $

NCCI Number:

NCCI Experience Modification Number:

What type of coverage do you have?

About Your Business

Number of full-time employees*

Number of part-time employees:*

How many years in business*

How many locations*

Estimated annual Payroll* $

Please give a brief description of your business (below):*

Employee Information

Employee #1

Classification Code

Estimate Yearly Payroll $

Employee #2

Classification Code

Estimate Yearly Payroll $

Employee #3

Classification Code

Estimate Yearly Payroll $

Employee #4

Classification Code

Estimate Yearly Payroll $

Please list additional employees in the "Additional Comments" section below

Business Information

Please select all that apply to your business:

Additional Comments:

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Condominium

Personal Information

Name:*

Address:*

City:*

State:*

Zip:*

Property Address (if different from above):

City:

State:

Zip:

Day Phone:*

Night Phone:

Best Time to Call:
 AM PM

Email Address:*

Occupation:

How Long at Current Job: (years)

Date of Birth:

Smoker:

 Yes No

Current Insurance Information

Company Name (not agency):

Policy Expiration Date:

Premium Amount: $

Amount Insured For: $

Policy Type:
 Primary Secondary

Term:
 6 Months 1 Year Other:

Have you filed any property claims in the past 3 years? if "YES", please give us claim detail below:

 Yes No

Condo Information

Condo is:

 Owner occupied Rented to others

Living area Sq Ft:

Number of units in your building:

Year Built:

Copper Pluming?

 Yes No

Circuit Breakers?

 Yes No

Alarm System:

 Yes No

Is the home/apartment equipped with at least one working smoke alarm?
 Yes No

Do all exterior doors have deadbolt type locks?

 Yes No

Desired Coverages

Deductible:

Comprehensive Personal Liability:

Value of your Contents:

List any additional Coverage requirements below:

Additional Comments

Please give additional comments you feel appropriate for this question. If you have additional information where there was not enough space, please enter them here:

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Life / Health

Your Information

Your Name:*

Address:*

City:*

State:*

Zip Code:*

Phone:*

Best time to call:

Your Email:*

Information about yourself and family

Please enter information below for all to be covered

Self*

DOB:

SEX*
 M F

Marital Status:*
 M S

Occupation:

Height:*

Weight:*

Have you/they had any of the following health conditions?

Are you currently insured on any prescription medications for ongoing health conditions?
 Yes No

Life Coverage

Amount of coverage: $

Type of coverage:

Disability Income:
 Yes No

Long Term Care:  Yes No

Add Health Coverage?  Yes No

Spouse

Name:

DOB:

SEX
 M F

Occupation:

Height:

Weight:

Have you/they had any of the following health conditions?

Are you currently insured on any prescription medications for ongoing health conditions?
 Yes No

Life Coverage

Amount of coverage: $

Type of coverage:

Disability Income:
 Yes No

Long Term Care:  Yes No

Add Health Coverage?  Yes No

Child #1

Name:

DOB:

SEX
 M F

Occupation:

Marital Status:*
 M S

Height:

Weight:

Have you/they had any of the following health conditions?

Are you currently insured on any prescription medications for ongoing health conditions?
 Yes No

Life Coverage

Amount of coverage: $

Type of coverage:

Disability Income:
 Yes No

Long Term Care:  Yes No

Add Health Coverage?  Yes No

Child #2

Name:

DOB:

SEX
 M F

Occupation:

Marital Status:*
 M S

Height:

Weight:

Have you/they had any of the following health conditions?

Are you currently insured on any prescription medications for ongoing health conditions?
 Yes No

Life Coverage

Amount of coverage: $

Type of coverage:

Disability Income:
 Yes No

Long Term Care:  Yes No

Add Health Coverage?  Yes No

To add family members, please enter information on the "Additional Comments" section.

Health Coverages

Please check desired coverages below for your health plan

Additional Comments

Please give additional comments you feel appropriate for this question. If you have additional information where there was not enough space, please enter them here:

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Auto Insurance

General Information

Your Name:*

Address:*

City:*

State:*

Zip Code:*

Phone:*

Fax:

E-mail:*

Current Auto Insurance Information

Company Name:

Policy Expiration Date:

Premium Amount:

Term:

Other:

Vehicle Information

Total number of cars your family owns or leases:*

Please enter information for the first and second vehicles below.

Car #1

Year:*

Make:*

Model:*

Body Type:*

VIN #:*

Name of the Title Holder:*

Annual Milage:*

Drive to school/work?*
 Yes No

# of miles one way:

Airbags*
 Yes No

Car alarm*
 Yes No

If vehicle is kept at an address other than that listed above, please indicate below

City:

State:

Zip Code:

Car #2

Year:

Make:

Model:

Body Type:

VIN #:

Name of the Title Holder:

Annual Milage:

Drive to school/work?
 Yes No

# of miles one way:

Airbags:
 Yes No

Car alarm:
 Yes No

If vehicle is kept at an address other than that listed above, please indicate below

City:

State:

Zip Code:

Liability Limit - For All Cars

Choose either Bodily Injury and Property Damage

Bodily Injury:

Property Damage:

or Single Limit:

Deductibles and Misc.

Comprehensive Deductible

Car 1:

Car 2:

Collision Deductible

Car 1

Car 2

Towing Car 1
 Yes No

Towing Car 2
 Yes No

Loss of Use Car 1
 Yes No

Loss of Use Car 2
 Yes No

Driver Information

(include all licensed drivers in your household)

Driver #1

Driver's Name*

Drivers License Information*
DL#:

State:*

Years Licensed:*

Relation*

Date of Birth

Sex

Marital Status

Courses Completed Last 3 years
Drivers Ed

Accident Prevention

Driver #2

Driver's Name

Drivers License Information
DL#:

State:

Years Licensed:

Relation

Date of Birth

Sex

Marital Status

Courses Completed Last 3 years
Drivers Ed

Accident Prevention

Additional Comments

Please give any additional comments you feel appropriate for this quote. If you have additional information where there was not enough fields above, please enter them here.

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Umbrella

Personal Information

Your Name:*

Address:*

City:*

State:*

Zip Code:*

Day Phone:*

Night Phone:*

Best Time to Call:
 AM PM

E-mail:*

Employment Information

Applicant's Occupation:

Employer Name/Address:*

Years Employed:*

Co-Applicant's Occupation:

Employer Name/Address:*

Years Employed:*

Umbrella Information

Coverages

Policy Amount:* $

Retention:* $

Optional Coverages to Apply
Uninsured Motorist:* $

Underinsured Motorist:* $

Premiums

Basic: $

Residences: $

Automobiles: $

Recreational Vehicles: $

Uninsured Motorist: $

Underinsured Motorist: $

Watercraft: $

Other:

Other:

Primary Policy Information

Type of Policy

Company/Policy Number:

Policy Period:

Limits of Liability

Single Limit:

Bodily Injury

Property Damage:

Type of Policy

Company/Policy Number:

Policy Period:

Limits of Liability

Single Limit

Bodily Injury

Property Damage

Type of Policy

Company/Policy Number:

Policy Period:

Limits of Liability

Single Limit

Bodily Injury

Property Damage

Type of Policy

Company/Policy Number:

Policy Period:

Limits of Liability

Single Limit:

Bodily Injury

Property Damage:

Real Estate

Name:

Location:

Description:

Year Built:

Occupancy:

Name:

Location:

Description:

Year Built:

Occupancy:

Automobiles:

List All Autos Owned, Leased, or Furnished for Regular Use

Year:*

Make and Model:*

Year:

Make and Model:

Recreational Vehicles

List Motorcycle, Snowmobiles, Dune Buggies, MiniBikes, etc.

Year:

Type, Make and Model:

Year

Type, Make and Model

Watercraft

List All Watercraft Owned, Leased, Chartered, or Furnished for Regular Use

Year:

Type/Manufacturer/Model:

Length:

Horse Power

Max Speed

New Value

Current Value

Waters Navigated

Operator Information

List all Household Members & All Operators of Vehicles/Watercraft

Name:*

DOB:*

Auto DL# State Licensed:*

Vehicle, Craft, %Use, Etc:*

Name:

DOB:

Auto DL# State Licensed:

Vehicle, Craft, %Use, Etc:

Prior Experience/Losses

Please list losses on any primary or excess policies exceeding $5,000 during the last 5 years

Loss #1

Loss #2

General Information

Please answer yes if any of the following is true. If Yes, please explain.

(1) Any aircraft owned, leased, chartered, or furnished for regular use?
(2) Any Operators Convicted for any traffic violations during the last 3 years?
(3) Any operator have physical/mental impairment?
(4) Any swimming pool on premises?
(5) Any real estate, vehicles, watercraft, aircraft used commercially or for business purposes?
(6) Any real estate, vehicles, watercraft, aircraft, owned, hired, leased, or regularly used not covered by primary policies?
(7) Do you engage in any type of farming operation?
(8) Do you hold any non-remunerative positions?
(9) Any full-time employees?
(10) Any non-owned property exceeding $1,000 in value in your care, custody or control?
(11) Any business and/or professional activities included in the primary policy?
(12) Does any primary policy have reduced limits of liability or eliminate coverage for specific exposures?
(13) Any coverage declined, cancelled, or NonRenewed during the last 5 years?

Are any of the above statements true?
 Yes No If Yes, please list number and explain below:

Additional Comments

Please give any additional comments you feel appropriate for this quote. If you have additional information where there was not enough fields above, please enter them here.

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