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Is this a New Purchase?
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Purchase Date
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MM slash DD slash YYYY
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Will you do a major renovation on this property shortly after you purchase it?
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*
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Are there multiple dwellings on this property?
Yes
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Additional Property Coverage Interests
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Flood
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Yes
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Name of current home insurance company
Have Dogs?
Yes
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Breed(s) of Dog(s)
Any dogs have bite history?
*
Yes
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Home Information
Is home newly built?
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Home Currently Under Construction?
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Year Built
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# of Bathrooms
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2
3
4
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*
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*
Yes
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Has Fireplace?
*
Yes
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Pool Type
*
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*
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Does pool have a diving board?
*
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Has there been any updates to the Roof, Plumbing, Heating, or Electrical?
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Solar Panels?
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Number of Solar Panels
Value of Solar Panels
Does your home qualify for discounts?
(Check all that apply)
Deadbolts
Fire Extinguisher
Smoke Alarm
Monitored Smoke Alarm
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Gas Leak Detector
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Military
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What types of detached structures?
Guest House
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Shed
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Other type of detached structure
Does home have an elevator?
Yes
No
Any trampoline?
Yes
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Any domestic employees?
Yes
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If you would like to attach any pictures of your home inside and/or outside, please do so here.
Drop files here or
Select files
Max. file size: 3 MB, Max. files: 6.
Valuable Items
Most home insurance policies allow you to schedule valuable items to your policy such as jewelry, fine art, firearms, antiques, bikes, cameras, certain electronics, collectibles, musical instruments, silverware, etc. If you would like to include any of these items, please do so below. If an item is ineligible for scheduling to your policy we will let you know.
Do you have any items you would like to schedule to your homeowners policy?
Yes
No
Let's Discuss
List of Scheduled Items
Item Description
Item Value ($)
Do you have an appraisal?
Yes
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Add
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Additional Drivers
Are there additional drivers in your household?
Yes
No
Additional Driver 1
1. Driver Name
*
First
Last
1. Driver Date of Birth
*
MM slash DD slash YYYY
1. Gender
*
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Female
Male
Prefer not to answer
1. Driver License #
*
1. Drivers License State
*
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1. Relationship to Insured
*
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Spouse
Child
Domestic Partner
Parent
Relative
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Other
Add 2nd Driver
Add Another Driver
Additional Driver 2
2. Driver Name
*
First
Last
2. Driver Date of Birth
*
MM slash DD slash YYYY
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Female
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Prefer not to answer
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*
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
2. Relationship to Insured
*
- Select -
Spouse
Child
Domestic Partner
Parent
Relative
Employee
Other
Add 3rd Driver
Add Another Driver
Additional Driver 3
3. Driver Name
*
First
Last
3. Driver Date of Birth
*
MM slash DD slash YYYY
3. Gender
*
- Select -
Female
Male
Prefer not to answer
3. Driver License #
*
3. Drivers License State
*
- Select State -
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Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
3. Relationship to Insured
*
- Select -
Spouse
Child
Domestic Partner
Parent
Relative
Employee
Other
Add 4th Driver
Add Another Driver
Additional Driver 4
4. Driver Name
*
First
Last
4. Driver Date of Birth
*
MM slash DD slash YYYY
4. Gender
*
- Select -
Female
Male
Prefer not to answer
4. Driver License #
*
4. Drivers License State
*
- Select State -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
4. Relationship to Insured
*
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Spouse
Child
Domestic Partner
Parent
Relative
Employee
Other
Add 5th Driver
Add Another Driver
Additional Driver 5
5. Driver Name
*
First
Last
5. Driver Date of Birth
*
MM slash DD slash YYYY
5. Gender
*
- Select -
Female
Male
Prefer not to answer
5. Driver License #
*
5. Drivers License State
*
- Select State -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
5. Relationship to Insured
*
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Spouse
Child
Domestic Partner
Parent
Relative
Employee
Other
Add 6th Driver
Add Another Driver
Additional Driver 6
6. Driver Name
*
First
Last
6. Driver Date of Birth
*
MM slash DD slash YYYY
6. Gender
*
- Select -
Female
Male
Prefer not to answer
6. Driver License #
*
6. Drivers License State
*
- Select State -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
6. Relationship to Insured
*
- Select -
Spouse
Child
Domestic Partner
Parent
Relative
Employee
Other
Vehicle 1
1. VIN
1. Year
*
1. Make
*
1. Model
*
1. Estimated Annual Miles
1. Primary Use
Pleasure
To/From Work
Business
1. Ownership
Own
Lease
1. Vehicle Financed
No
Yes
1. Preferred COMPREHENSIVE Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
1. Preferred COLLISION Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
1. Name of Primary Driver
Add 2nd Vehicle
Add a Vehicle
Vehicle 2
2. VIN
2. Year
*
2. Make
*
2. Model
*
2. Estimated Annual Miles
2. Primary Use
Pleasure
To/From Work
Business
2. Ownership
Own
Lease
2. Vehicle Financed
No
Yes
2. Preferred COMPREHENSIVE Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
2. Preferred COLLISION Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
2. Name of Primary Driver
Add 3rd Vehicle
Add a Vehicle
Vehicle 3
3. VIN
3. Year
*
3. Make
*
3. Model
*
3. Estimated Annual Miles
3. Primary Use
Pleasure
To/From Work
Business
3. Ownership
Own
Lease
3. Vehicle Financed
No
Yes
3. Preferred COMPREHENSIVE Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
3. Preferred COLLISION Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
3. Name of Primary Driver
Add 4th Vehicle
Add a Vehicle
Vehicle 4
4. VIN
4. Year
*
4. Make
*
4. Model
*
4. Estimated Annual Miles
4. Primary Use
Pleasure
To/From Work
Business
4. Ownership
Own
Lease
4. Vehicle Financed
No
Yes
4. Preferred COMPREHENSIVE Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
4. Preferred COLLISION Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
4. Name of Primary Driver
Add 5th Vehicle
Add a Vehicle
Vehicle 5
5. VIN
5. Year
*
5. Make
*
5. Model
*
5. Estimated Annual Miles
5. Primary Use
Pleasure
To/From Work
Business
5. Ownership
Own
Lease
5. Vehicle Financed
No
Yes
5. Preferred COMPREHENSIVE Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
5. Preferred COLLISION Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
5. Name of Primary Driver
Add 6th Vehicle
Add a Vehicle
Vehicle 6
6. VIN
6. Year
*
6. Make
*
6. Model
*
6. Annual Miles Driven
6. Primary Use
Pleasure
To/From Work
Business
6. Ownership
Own
Lease
6. Vehicle Financed
No
Yes
6. Preferred COMPREHENSIVE Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
6. Preferred COLLISION Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
6. Name of Primary Driver
Add 7th Vehicle
Add a Vehicle
Vehicle 7
7. VIN
7. Year
*
7. Make
*
7. Model
*
7. Annual Miles Driven
7. Primary Use
Pleasure
To/From Work
Business
7. Ownership
Own
Lease
7. Vehicle Financed
No
Yes
7. Preferred COMPREHENSIVE Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
7. Preferred COLLISION Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
7. Name of Primary Driver
Add 8th Vehicle
Add a Vehicle
Vehicle 8
8. VIN
8. Year
*
8. Make
*
8. Model
*
8. Annual Miles Driven
8. Primary Use
Pleasure
To/From Work
Business
8. Ownership
Own
Lease
8. Vehicle Financed
No
Yes
8. Preferred COMPREHENSIVE Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
8. Preferred COLLISION Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
8. Name of Primary Driver
Add 9th Vehicle
Add a Vehicle
Vehicle 9
9. VIN
9. Year
*
9. Make
*
9. Model
*
9. Annual Miles Driven
9. Primary Use
Pleasure
To/From Work
Business
9. Ownership
Own
Lease
9. Vehicle Financed
No
Yes
9. Preferred COMPREHENSIVE Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
9. Preferred COLLISION Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
9. Name of Primary Driver
Add 10th Vehicle
Add a Vehicle
Vehicle 10
10. VIN
10. Year
*
10. Make
*
10. Model
*
10. Annual Miles Driven
10. Primary Use
Pleasure
To/From Work
Business
10. Ownership
Own
Lease
10. Vehicle Financed
No
Yes
10. Preferred COMPREHENSIVE Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
10. Preferred COLLISION Deductible
*
- Select -
None
100
200
300
500
1000
2000
3000
5000
10000
Unsure
10. Name of Primary Driver
Special Motorcycle Coverages
Enhanced Injury Protection
Yes
No
Physical Damage
Actual Cash Value
None - Liability Only
Roadside Assistance
None
Roadside
Roadside w/ Trip Interruption
Carried Contents
None
$1,000
$2,000
$3,000
Accessories Coverage
$1 - $3,000
$3,001 - $4,000
$4,001 - $5,000
$5,001 - $6,000
$6,001 - $7,000
$7,001 - $10,000
$10,001 - $15,000
$15,001 - $20,000
$20,001 - $25,000
$25,001 - $30,000
Safety & Riding Apparel
$1 - $500
$501 - $1,000
$1,001 - $1,500
$1,501 - $2,000
$2,001 - $2,500
$2,501 - $3,000
Transport Trailer Coverage?
Yes
No
Trailer Value
Boat Information
Serial Number
*
Year
*
Make
*
Model
*
Hull ID Number
Boat Registration Number
This is the ID number assigned to your boat by the state.
Hull Material
- Select -
Fiberglass
Aluminum
Wood
Inflatable
Steel
Other
Number of Motors
1
2
3+
Propulsion Type
- Select -
Inboard
Outboard
Inboard / Outboard
Jet
Max Horsepower
Max Speed
Current Value
Fishing Equipment Coverage
None
$1,000
$2,500
$5,000
$10,000
Insure the Trailer?
Yes
No
RV, Trailer, or Camper Information
Year
*
Make
*
Model
*
VIN
Length (in feet)
*
Please enter a number greater than or equal to
2
.
Year Purchased
*
Value (estimated ACV)
*
Garaging Zipcode
*
Number of days RV used per year
*
Original Owner?
*
Yes
No
Is there a lienholder?
*
Yes
No
RV Lienholder Name
Is RV parked at a single location year round?
*
Yes
No
Is RV rented commercially or used for business purposes?
*
Yes
No
Is RV rented out to others?
*
Yes
No
Is RV taken to/from work or used at a work location?
*
Yes
No
Umbrella Coverage Information
Number of Properties
1
2
3
4
5
6
7
8
9
10
Number of Vehicles
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Number of Watercraft
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Number of Drivers
1
2
3
4
5
6
7
8
9
10
Number of Drivers (under age 25)
0
1
2
3
4
5
6
7
8
9
10
Number of Drivers (over age 75)
0
1
2
3
4
5
6
7
8
9
10
Liability Limit
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
$10,000,000
$20,000,000
Greater than $20,000,000
Wrapping Up
Any Claims in the Past Three (3) Years?
*
Yes
No
Please describe past claims
*
Any lapse in Home insurance in the past year?
Yes
No
Not Applicable
Any lapse in Auto insurance in the past year?
Yes
No
Not Applicable
Do you need any SR-22 filings?
*
Yes
No
Do you have any auto insurance currently?
Yes
No
Name of current auto insurance company
Additional Comments
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Albert Martinez
Sara Martinez
Mike Garcia
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