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Questions For Quote
Questions For Quote
Collin Randlolph
2021-12-03T19:36:05+00:00
Step
1
of
4
25%
General Contact Information
Name
First
Last
Date
Year
Month
Day
Current Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
Email
How did you hear about us?
What type of quote are you interested in?
Please note that for the most competitive rates a bundled insurance package of home and auto is required.
Home
Auto
Other Insurance
Do you have any specific requests or goals that you are trying to achieve with your new insurance plan?
Please select a quote type to continue.
Home Insurance
Owner / Resident Information
Person 1 - Owner / Primary Contact
Name
First
Last
Date of Birth
(Required)
Year
Month
Day
Driver's License / State ID
Occupation
Person 2 - Owner / Spouse / Significant Other
Name
First
Last
Relationship to Person 1
Please choose
Spouse
Child
Parent
Employee
Other
Date of Birth
Year
Month
Day
Driver's License / State ID
Occupation
Total number of residents, including the Owner(s)
1
2
3
4
5
6
Number of Homes to quote
1
2
Home Location 1 Information
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Is this a primary residence or rental property?
Primary residence
Rental property
Is there short term rental activity at this location?
Yes
No
Are there any businesses on the premises?
Yes
No
Year Built
Date of Purchase
(Required)
Year
Month
Day
Total Square Feet
Above Ground Square Feet
Home Type
Single family home
Apartment
Condo
Townhouse
Rowhouse
Co-op
Mobile/Manufactured
Foundation Type
Slab
Crawl Space
Basement
Deep Pilings
Elevated Post/Pier and Beam
Style of Home
2-story
Rambler
Split level
Other
Roof Material
Architechtural Shingle
Composite Shingle
Wood Shake/Shingle
Concrete Tile
Clay Tile
Metal
Flat
Built Up
Other
Type of Siding
Frame
Masonry
Masonry Veneer
Fire Resistive
Vinyl Siding
Aluminum Siding
Asbestos
Stucco
Log
EIFS
Hardiplank Siding
Type of Heating
Gas
Electric
Propane
Oil
Heat Pump
Geothermal
Radiant Floor
Number of Full Bathrooms
Number of 3/4 Bathrooms
Number of 1/2 Bathrooms
Number of Garaged Cars
The number of cars that fit within the garage of the home.
Is there a basement?
Yes
No
What percentage of basement is finished?
Please enter a number from
0
to
100
.
Type of Basement
Please Choose
Walkout
Daylight
Slab
Crawl space
Are there any fireplaces?
Yes
No
Number of Fireplaces
Type of Fireplace
Fireplace Insert
Fireplace Masonry
Fireplace Prefab
Do you own any dogs?
Yes
No
Dog Breed
Does the dog have a bite history?
Yes
No
Is there an alarm system?
Yes
No
What type of alarm?
Burglar
Fire
Water
Auto water shut off
Low temp
How is the alarm system monitored?
Please Choose
Central
Local
Is there water or temperature monitoring?
Yes
No
Type of kitchen
Builders Grade
Custom
Semi-custom
Other
Is there a pool?
Yes
No
Type of pool
Inground
Above ground
Pool Square Footage
Is there a fence around the pool?
Yes
No
Is there a trampoline on the property?
Yes
No
List any detached structures on the property (shed, pole barn, detached garage, pool house, etc.)
Are there any current or upcoming renovation projects?
Yes
No
What year was the roof last updated?
What year was the heating last updated?
What year was the electrical last updated?
What year was the plumbing last updated?
Mortgage company name
Mortgage company address
Are there any residents in the home that are not listed?
Yes
No
List all additional residents
Home Location 2 Information
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Is this a primary residence or rental property?
Primary residence
Secondary residence
Rental property
Is there short term rental activity at this location?
Yes
No
Are there any businesses on the premises?
Yes
No
Year built
Date of Purchase
(Required)
Year
Month
Day
Total Square Feet
Above Ground Square Feet
Home Type
Single Family Home
Apartment
Condo
Townhouse
Rowhouse
Co-op
Mobile/Manufactured
Other
Foundation Type
Slab
Crawl Space
Basement
Deep Pilings
Elevated Post/Pier and Beam
Style of Home
2-story
Rambler
Split level
Roof Material
Architechtural Shingle
Composite Shingle
Wood Shake/Shingle
Concrete Tile
Clay Tile
Metal
Flat
Built Up
Other
Type of Siding
Frame
Masonry
Masonry Veneer
Fire Resistive
Aluminum Siding
Asbestos
Stucco
Log
EIFS
Hardiplank Siding
Type of Heating
Gas
Electric
Propane
Oil
Heat Pump
Geothermal
Radiant Floor
Number of Full Bathrooms
Number of 3/4 Bathrooms
Number of 1/2 Bathrooms
Number of Cars Garaged
The number of cars that fit within the garage of the home.
Is there a basement?
Yes
No
What percentage of basement is finished?
The number of cars that fit within the garage of the home.
Type of Basement
Please Choose
Walkout
Daylight
Slab
Crawl space
Are there any fireplaces?
Yes
No
Number of Fireplaces
Type of Fireplace
Fireplace Insert
Fireplace Masonry
Fireplace Prefab
Do you own any dogs?
Yes
No
Dog Breed
Does the dog have a bite history?
Yes
No
Is there an alarm system?
Yes
No
What type of alarm?
Burglar
Fire
Water
Auto water shut off
Low temp
How is the alarm system monitored?
Please Choose
Central
Local
Is there water or temperature monitoring?
Yes
No
Type of Kitchen
Builders Grade
Custom
Semi-custom
Is there a pool?
Yes
No
Type of Pool
Inground
Above ground
Pool Square Footage
Is there a fence around the pool?
Yes
No
Is there a trampoline on the property?
Yes
No
List any detached structures on the property (shed, pole barn, detached garage, pool house, etc.)
Are there any current or upcoming renovation projects?
Yes
No
What year was the roof last updated?
What year was the heating last updated?
What year was the electrical last updated?
What year was the plumbing last updated?
Mortgage Company Name
Mortgage Company Address
Are there any residents in the home that are not listed?
Yes
No
List All Additional Residents
Vehicle Insurance
How many driver licensed / driver permited people will be covered under this insurance policy?
(Required)
1
2
3
4
5
6
How many cars will be covered under this insurance policy?
(Required)
1
2
3
4
5
6
Driver 1
Name
(Required)
First
Last
Date of Birth
(Required)
Year
Month
Day
Driver's License / Permit License Number
(Required)
State that Issued License
(Required)
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Occupation
Is this driver a student?
Yes
No
Is this driver away at school over 100 miles from your home?
Yes
No
What is the location? (Provide address if possible.)
Does this driver have a vehicle with them at school?
Yes
No
Which vehicle does this driver have at school?
Does this driver maintain a B average or better in school?
Yes
No
Driver 2
Name
First
Last
Date of Birth
Year
Month
Day
Driver's License / Permit License Number
State that Issued License
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Occupation
Is this driver a student?
Yes
No
Is this driver away at school over 100 miles from your home?
Yes
No
What is the location? (Provide address if possible.)
Does this driver have a vehicle with them at school?
Yes
No
Which vehicle does this driver have at school?
Does this driver maintain a B average or better in school?
Yes
No
Driver 3
Name
First
Last
Date of Birth
Year
Month
Day
Driver's License / Permit License Number
State that Issued License
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Occupation
Is this driver a student?
Yes
No
Is this driver away at school over 100 miles from your home?
Yes
No
What is the location? (Provide address if possible.)
Does this driver have a vehicle with them at school?
Yes
No
Which vehicle does this driver have at school?
Does this driver maintain a B average or better in school?
Yes
No
Driver 4
Name
First
Last
Date of Birth
Year
Month
Day
Driver's License / Permit License Number
State that Issued License
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Occupation
Is this driver a student?
Yes
No
Is this driver away at school over 100 miles from your home?
Yes
No
What is the location? (Provide address if possible.)
Does this driver have a vehicle with them at school?
Yes
No
Which vehicle does this driver have at school?
Does this driver maintain a B average or better in school?
Yes
No
Driver 5
Name
First
Last
Date of Birth
Year
Month
Day
Driver's License / Permit License Number
State that Issued License
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Occupation
Is this driver a student?
Yes
No
Is this driver away at school over 100 miles from your home?
Yes
No
What is the location? (Provide address if possible.)
Does this driver have a vehicle with them at school?
Yes
No
Which vehicle does this driver have at school?
Does this driver maintain a B average or better in school?
Yes
No
Driver 6
Name
First
Last
Date of Birth
Year
Month
Day
Driver's License / Permit License Number
State that Issued License
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Occupation
Is this driver a student?
Yes
No
Is this driver away at school over 100 miles from your home?
Yes
No
What is the location? (Provide address if possible.)
Does this driver have a vehicle with them at school?
Yes
No
Which vehicle does this driver have at school?
Does this driver maintain a B average or better in school?
Yes
No
Vehicle 1
Year
Make
Model
VIN
Primary driver
Was vehicle purchased new?
Yes
No
Vehicle Purchase Price
Vehicle usage (select all that apply)
Business
Pleasure
Commute
Annual mileage
Is this vehicle used to deliver goods or as a transportation service (Uber / Lyft)?
Yes
No
Have there been any claims or driving infractions in the past five years?
Vehicle 2
Year
Make
Model
VIN
Primary driver
Was vehicle purchased new?
Yes
No
Vehicle Purchase Price
Vehicle usage (select all that apply)
Business
Pleasure
Commute
Annual mileage
Is this vehicle used to deliver goods or as a transportation service (Uber / Lyft)?
Yes
No
Have there been any claims or driving infractions in the past five years?
Vehicle 3
Year
Make
Model
VIN
Primary driver
Was vehicle purchased new?
Yes
No
Vehicle Purchase Price
Vehicle usage (select all that apply)
Business
Pleasure
Commute
Annual mileage
Is this vehicle used to deliver goods or as a transportation service (Uber / Lyft)?
Yes
No
Have there been any claims or driving infractions in the past five years?
Vehicle 4
Year
Make
Model
VIN
Primary driver
Was vehicle purchased new?
Yes
No
Vehicle Purchase Price
Vehicle usage (select all that apply)
Business
Pleasure
Commute
Annual mileage
Is this vehicle used to deliver goods or as a transportation service (Uber / Lyft)?
Yes
No
Have there been any claims or driving infractions in the past five years?
Vehicle 5
Year
Make
Model
VIN
Primary driver
Was vehicle purchased new?
Yes
No
Vehicle Purchase Price
Vehicle usage (select all that apply)
Business
Pleasure
Commute
Annual mileage
Is this vehicle used to deliver goods or as a transportation service (Uber / Lyft)?
Yes
No
Have there been any claims or driving infractions in the past five years?
Vehicle 6
Year
Make
Model
VIN
Primary driver
Was vehicle purchased new?
Yes
No
Vehicle Purchase Price
Vehicle usage (select all that apply)
Business
Pleasure
Commute
Annual mileage
Is this vehicle used to deliver goods or as a transportation service (Uber / Lyft)?
Yes
No
Have there been any claims or driving infractions in the past five years?
Do you have any other items to ensure?
Rental Property
Motorcycle/ATV
Snowmobile
Boat
Jewelry/Collectibles
Additional Residences
Other
Other
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