Agent Quote Form - Internal Use Only

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Primary Address (New Purchase Address)*
Street Address Address Line 2 City State ZIP Code
At this address less than 2 year?
Prior Address
Street Address Address Line 2 City State ZIP Code

If at current address less than 2 years

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Short Term or Long Term Rental?
Long term = 6 month or longer lease.
Rental Property Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Using a Property Manager?
Additional Rental Property(s) to add?*
Additional Rental Properties to Quote - List Addresses

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View Photos of the Home online if possible (Zillow, Realtor.com, Movoto, etc.)
Verify this information with the prospect.
Primary Home?
Year Built*
Square Footage*
# of Stories*
Primary Exterior Construction*
Basement

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Roof Type*
Year Roof Replaced
Check all exposures that apply*
- Fireplace
- Woodstove
- Inground Pool
- Above Ground Pool
- Trampoline
- Large Trees Near Home
- Other Risk Exposure
- None
Is there an Attached or Built-In Garage?*
Pets?*
Types of pets & breed...*

Animals with a bite history are NOT allowed.
Any expensive items you want to make sure are fully insured?*
We can either schedule them or write separately with Jeweler's Mutual or Travelers. *This excludes TVs & Computers. Think of unique items such as jewelry, cameras, sporting equipment, fine art, etc.
Scheduled Item(s)

Simple Description & Approx. Value
Current Auto Insurance Carrier*

Because we have several carriers, we may still be able to get the client a multi-policy discount if they already are insured with a carrier we have.
Additional Updates or Information...

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Current Auto Carrier*
Current Bodily Injury Limits
If Unknown, simply select the limit for us to quote.
Vehicle 1 - Year, Make, Model, & VIN*
Vehicle 1 - Coverage
- Comprehensive
- Collision
- Liability Only
Vehicle 2 - Year, Make, Model, & VIN
Vehicle 2 - Coverage
- Comprehensive
- Collision
- Liability Only
Add Additional Vehicle, Motorcycle, RV, or Trailer?*

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Vehicle 3 - Year, Make, Model, & VIN
Vehicle 3 - Coverage
- Comprehensive
- Collision
- Liability Only
Vehicle 4 - Year, Make, Model, & VIN
Vehicle 4 - Coverage
- Comprehensive
- Collision
- Liability Only
Add even more vehicles?*
Additional Vehicles to Add - Year, Make, Model, & VIN
Include desired coverage for these vehicles...

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Agent Quote Form – Internal Use Only