Agent Quote Form – Internal Use Only Step 1 of 14 7% Prmary First Name* First Last What is the best phone number to reach you at?*Your Email* Preferred Contact Method*PhoneEmailTextHow did you find our agency?* Google Search Facebook/Instagram Ad Customer Referral Loan Officer Realtor RightWay Agent BNI Other Producer*Ryan McGrewNicole BrunnerConnor LinvilleWho referred you to us?* We love working with "________" they do a great job! What policies can we quote for you today?*Typically, we quote HOME & AUTO to make sure that you're getting the best rates available. {Check All That Apply} Auto Home Condo Renters Rental Property Umbrella Motorcycle Boat & Jet Ski Is this client in the process of purchasing a new home?*NoYesProjected Closing Date MM slash DD slash YYYY Primary Address (New Purchase Address)* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code At this address less than 2 year?NoYesPrior Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code If at current address less than 2 years Short Term or Long Term Rental?Long-TermShort-Term (AirBNB, Overnight Rental)Long term = 6 month or longer lease.Rental Property Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Using a Property Manager?NoYesAdditional Rental Property(s) to add?*NoYesAdditional Rental Properties to Quote - List Addresses View Photos of the Home online if possible (Zillow, Realtor.com, Movoto, etc.)Verify this information with the prospect.Primary Home?YesNoRentalYear Built*Square Footage*# of Stories*1 -Story1 - Story w/Basement1.5 - Stories1.5 - Stories w/Basement2 - Stories2 - Stories w/Basement3 - Stories3 - Stories w/BasementBi-Level / Split-LevelPrimary Exterior Construction*Frame - with SidingMasonry / Brick VeneerLogOtherBasementFull Finished BasementUnfinished BasementPartially Finished Basement Roof Type*Asphalt ShingleArchitectural ShingleMetalSlateOtherYear 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?*No1 Car2 Car3 CarPets?*NoYesTypes of pets & breed...* Animals with a bite history are NOT allowed.Any expensive items you want to make sure are fully insured?*NoYesWe 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. ValueCurrent 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... Insured / Driver InfoNamed Insured / Driver #1* First Last Date of Birth* MM slash DD slash YYYY License Number and State Marital Status*SingleMarriedDivorced/WidowedOccupation Add a Driver or Named Insured?*NoYesSPOUSES MUST BE ADDED 2nd Named Insured / Driver # 2* First Last Driver #2 Date of Birth* MM slash DD slash YYYY Driver #2 Driver's License Number & State Driver #2 Marital Status*SingleMarriedDivorced/WidowedDriver #2 Occupation Add another driver?NoYesAdditional Drivers - Full Name, Date of Birth, & Driver's License Number Current Auto Carrier* Current Bodily Injury Limits25/50/2550/100/50100/300/100250/500/100500/500/500300 CSL500 CSLIf 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?*NoYes 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?*NoYesAdditional Vehicles to Add - Year, Make, Model, & VINInclude desired coverage for these vehicles... Watercraft 1 - Year, Make, Model, & Horsepower Watercraft 1 - Coverage Comprehensive Collision Liability Only Value Where will it be stored? At Residence At Marina In-Water Dry Storage Locked Garage/Building Storage Yard Add another watercraft?*NoYes Watercraft 2 - Year, Make, Model, & Horsepower Watercraft 2 - Coverage Comprehensive Collision Liability Only Value - Watercraft #2 Where will it be stored? Watercraft -#2 At Residence At Marina In-Water Dry Storage Locked Garage/Building Storage Yard Umbrella Policy Limit$1M$2M$3M$5M+ Additional Notes Regarding This Account
