Staff Quote Application

Current Insurance Company

Effective Date

Length of Time with Current Company

Own or Rent?

Driver 1

Name*

First Name

Last Name

Date of Birth*

Driver's License Number*

Would You Like To Add Another Driver?*

No Yes

Driver 2

Name*

First Name

Last Name

Date of Birth*

Driver's License Number*

Would You Like To Add Another Driver?*

Yes No

Driver 3

Name*

First Name

Last Name

Date of Birth*

Driver's License Number*

Would You Like To Add Another Driver?*

Yes No

Driver 4

Name*

First Name

Last Name

Date of Birth*

Driver's License Number*

Would You Like To Add Another Driver?*

Yes No

Driver 5

Name*

First Name

Last Name

Date of Birth*

Driver's License Number*

Vehicle 1

Year*

Make*

Model*

Would You Like To Add Another Vehicle?*

Yes No

Vehicle 2

Year*

Make*

Model*

Would You Like To Add Another Vehicle?*

Yes No

Vehicle 3

Year*

Make*

Model*

Would You Like To Add Another Vehicle?*

Yes No

Vehicle 4

Year*

Make*

Model*

Would You Like To Add Another Vehicle?*

Yes No

Vehicle 5

Year*

Make*

Model*

Would You Like To Add Another Vehicle?*

Yes No

Vehicle 6

Year*

Make*

Model*

Would You Like To Add Another Vehicle?*

Yes No

Vehicle 7

Year*

Make*

Model*

Would You Like To Add Another Vehicle?*

Yes No

Vehicle 8

Year*

Make*

Model*

Would You Like To Add Another Vehicle?*

Yes No

Vehicle 9

Year*

Make*

Model*

Would You Like To Add Another Vehicle?*

Yes No

Vehicle 10

Year*

Make*

Model*

Property Information

Coverage Option

Roof Year

Last year roof was replaced. If new build please put date of construction.

Do you have a dog?

Dog Breed

Please list any dog breeds that reside at your home.

Rental/Dwelling Properties

Property Address

Address Line 1

Address Line 2

City

State

ZIP Code

Tenant Occupied or Vacant

Home deed to a business

Claims on property in last 5 years

Boat 1

Boat ID*

Year*

Make*

Model*

Would You Like To Add Another Boat?*

Yes No

Boat 2

Boat ID*

Year*

Make*

Model*

Would You Like To Add Another Boat?*

Yes No

Boat 3

Boat ID*

Year*

Make*

Model*

Would You Like To Add Another Boat?*

Yes No

Boat 4

Boat ID*

Year*

Make*

Model*

Would You Like To Add Another Boat?*

Yes No

Boat 5

Boat ID*

Year*

Make*

Model*

Hull Material

Propulsion Type

Number of Motors

Motor 1

Year*

Make*

Model*

Motor 2

Year*

Make*

Model*

Motor 3

Year*

Make*

Model*

Motor 4

Year*

Make*

Model*

Motor 5

Year*

Make*

Model*

Total Horsepower

Maximum Speed

Is the engine modified for enhanced performance?

Would you like to insure your trailer?

Trailer 1

Year*

Make*

Model*

Would You Like To Add Another Trailer?*

Yes No

Trailer 2

Year*

Make*

Model*

Would You Like To Add Another Trailer?*

Yes No

Trailer 3

Year*

Make*

Model*

Would You Like To Add Another Trailer?*

Yes No

Trailer 4

Year*

Make*

Model*

Would You Like To Add Another Trailer?*

Yes No

Trailer 5

Year*

Make*

Model*

Market Value of Watercraft

Year Boat Purchased

Coverage

RV Full Timer?

What Kind of RV?

What Kind of MotorHome?

What Kind of Travel Trailer?

How long is the RV?

Purchase Price $

Any Slide-Outs?

Number of Slide-Outs

Is the RV permanently parked?

Where?

Lojack Installed

Modified Frame

Registered for On-Road Use

Is this a Trike?

Year Purchased

Original Owner

Accessory Coverage Needed

How Much?

Have you completed a safety course?

Coverage

Lead Installer

First Name

Last Name

Name of Your Business

Website

FEIN or Tax ID Number

Business Location

Same as Personal Address

Business Location

Address Line 1

Address Line 2

City

State

ZIP Code

Do you need General Liability?

Do you need Workers Comp?

Do you need Inland Marine?

Annual Revenue $

Estimated Annual Sales $

Annual Payroll $

Number of Employees

Give A Brief Description of Your Business

Employee Driver 1

Name

First Name

Last Name

Date of Birth

Drivers License Number

Would You Like To Add Another Driver?

Yes No

Employee Driver 2

Name

First Name

Last Name

Date of Birth

Drivers License Number

Would You Like To Add Another Driver?

Yes No

Employee Driver 3

Name

First Name

Last Name

Date of Birth

Drivers License Number

Would You Like To Add Another Driver?

Yes No

Employee Driver 4

Name

First Name

Last Name

Date of Birth

Drivers License Number

Would You Like To Add Another Driver?

Yes No

Employee Driver 5

Name

First Name

Last Name

Date of Birth

Drivers License Number

Would You Like To Add Another Driver?

Yes No

Employee Driver 6

Name

First Name

Last Name

Date of Birth

Drivers License Number

Would You Like To Add Another Driver?

Yes No

Employee Driver 7

Name

First Name

Last Name

Date of Birth

Drivers License Number

Would You Like To Add Another Driver?

Yes No

Employee Driver 8

Name

First Name

Last Name

Date of Birth

Drivers License Number

Would You Like To Add Another Driver?

Yes No

Employee Driver 9

Name

First Name

Last Name

Date of Birth

Drivers License Number

Would You Like To Add Another Driver?

Yes No

Employee Driver 10

Name

First Name

Last Name

Date of Birth

Drivers License Number

Business Vehicle 1

Year*

Make*

Model*

Would You Like To Add Another Vehicle?*

Yes No

Business Vehicle 2

Year*

Make*

Model*

Would You Like To Add Another Vehicle?*

Yes No

Business Vehicle 3

Year*

Make*

Model*

Would You Like To Add Another Vehicle?*

Yes No

Business Vehicle 4

Year*

Make*

Model*

Would You Like To Add Another Vehicle?*

Yes No

Business Vehicle 5

Year*

Make*

Model*

Would You Like To Add Another Vehicle?*

Yes No

Business Vehicle 6

Year*

Make*

Model*

Would You Like To Add Another Vehicle?*

Yes No

Business Vehicle 7

Year*

Make*

Model*

Would You Like To Add Another Vehicle?*

Yes No

Business Vehicle 8

Year*

Make*

Model*

Would You Like To Add Another Vehicle?*

Yes No

Business Vehicle 9

Year*

Make*

Model*

Would You Like To Add Another Vehicle?*

Yes No

Business Vehicle 10

Year*

Make*

Model*

Coverage Option

Term or Whole Life?

Term Period

Amount of Coverage Needed $

Do you currently have Health Insurance?

Is your health insurance with your employer or through the marketplace (Healthcare.gov)?

Name of Employer

Employer's Phone

Annual Salary $

Hourly Wage $

Hours per Week

Name of Doctor/Specialist

Name of your current carrier.

Do you have a healthcare.gov account?

Have you had a Special Event that might affect your health insurance?

Loss of coverage in the last 60 days. Losing coverage in the next 60 days. Are you recently married? Are you recently divorced? Are you moving? Are you turning 26? Are you losing Medicaid? Are you gaining citizenship?

Other:

Check all that apply.

Farm Building 1

Type

Year Built

Sq/Ft

Would You Like To Add Another Building?

Yes No

Farm Building 2

Type

Year Built

Sq/Ft

Would You Like To Add Another Building?

Yes No

Farm Building 3

Type

Year Built

Sq/Ft

Would You Like To Add Another Building?

Yes No

Farm Building 4

Type

Year Built

Sq/Ft

Farm Building 5

Type

Year Built

Sq/Ft

Farm Animal 1

Type

How Many?

Would You Like To Add Another Farm Animal?

Yes No

Farm Animal 2

Type

How Many?

Would You Like To Add Another Farm Animal?

Yes No

Farm Animal 3

Type

How Many?

Would You Like To Add Another Farm Animal?

Yes No

Farm Animal 4

Type

How Many?

Farm Animal 5

Type

How Many?

Horse Breed 1

Type

How Many?

Would You Like To Add Another Horse Breed?

Yes No

Horse Breed 2

Type

How Many?

Would You Like To Add Another Horse Breed?

Yes No

Horse Breed 3

Type

How Many?

Would You Like To Add Another Horse Breed?

Yes No

Horse Breed 4

Type

How Many?

Would You Like To Add Another Horse Breed?

Yes No

Horse Breed 5

Type

How Many?

Crops 1

Type

Acres

Value $

Would You Like To Add Another Crop?

Yes No

Crops 2

Type

Acres

Value $

Would You Like To Add Another Crop?

Yes No

Crops 3

Type

Acres

Value $

Would You Like To Add Another Crop?

Yes No

Crops 4

Type

Acres

Value $

Would You Like To Add Another Crop?

Yes No

Crops 5

Type

Acres

Value $

Farm Vehicle 1

Year

Make

Model

VIN

Value $

Would You Like To Add Another Vehicle?

Yes No

Farm Vehicle 2

Year

Make

Model

VIN

Value $

Would You Like To Add Another Vehicle?

Yes No

Farm Vehicle 3

Year

Make

Model

VIN

Value $

Would You Like To Add Another Vehicle?

Yes No

Farm Vehicle 4

Year

Make

Model

VIN

Value $

Would You Like To Add Another Vehicle?

Yes No

Farm Vehicle 5

Year

Make

Model

VIN

Value $

Farm Equipment 1

Year

Make

Model

Serial #

Would You Like To Add More Equipment?

Yes No

Farm Equipment 2

Year

Make

Model

Serial #

Would You Like To Add More Equipment?

Yes No

Farm Equipment 3

Year

Make

Model

Serial #

Would You Like To Add More Equipment?

Yes No

Farm Equipment 4

Year

Make

Model

Serial #

Would You Like To Add More Equipment?

Yes No

Farm Equipment 5

Year

Make

Model

Serial #

Farm Employees

How Many

Full/Part Time

Salary $

Would You Like To Add More Employees?

Yes No

Farm Employees 2

How Many

Full/Part Time

Salary $

Other Coverage Needed

Cargo Refrigeration Equipment Breakdown Extra Expenses

Pollution Coverage Needed

Manure Exposure Chemical Spraying Transmission of Chemicals

Do You Need Farm Umbrella?

Address of New Build

Address Line 1

Address Line 2

City

State

ZIP Code

Type of Construction

Residential Commerical

Start Date of Construction

End Date of Construction

Value of Construction $

Type of Construction

Frame/Vinyl Siding Masonry/Brick Stucco Other

What type?

Number of Stories

Square Feet

Notes