Agent Quote Form - Internal Use Only

Prmary First Name*

First Last

What is the best phone number to reach you at?*

Your Email*

Preferred Contact Method*

How did you find our agency?*

Google Search

Facebook/Instagram Ad

Customer Referral

Loan Officer

Realtor

RightWay Agent

BNI

Other

Who referred you to us?*

We love working with "________" they do a great job!

EZLynx Assigned Producer*

EZLynx Assigned CSR*

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?*

Projected Closing Date

MM slash DD slash YYYY

Primary Address (New Purchase Address)*

Street Address Address Line 2 City State ZIP Code

At this address less than 2 year?

Manufactured Home?

Prior Address

Street Address Address Line 2 City State ZIP Code

If at current address less than 2 years

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

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

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...

Insured / Driver Info

Named Insured / Driver #1*

First Last

Date of Birth*

MM slash DD slash YYYY

License Number and State

Marital Status*

Occupation

Add a Driver or Named Insured?*

SPOUSES 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*

Driver #2 Occupation

Add another driver?

Additional Drivers - Full Name, Date of Birth, & Driver's License Number

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?*

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...

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?*

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

Send Completed Quotes to*

Additional Notes Regarding This Account

File

Max. file size: 98 MB.

Agent Quote Form – Internal Use Only

View Photos of the Home online if possible (Zillow, Realtor.com, Movoto, etc.)

Insured / Driver Info

Request Your Proposal Here