Auto and Home Insurance Questionnaire Auto and Home Insurance Questionnaire 1Household Information2Household Details3Household Members4Auto Insurance5Property (Homes, Cabins Rentals)6Recreational Vehicles, Boats7Farm Ranch8Earthquake - Flood9Life Health10Other Insurance Household InformationPrimary Contact Name(Required) First Last Primary Contact Phone(Required)Primary Contact Email(Required) Where can we send proposalsSecond Contact Name First Last Second Contact PhoneSecond Contact Email Primary Home Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Questionnaire ID Household Details Tell Us About Your Household Tell us about your Household. Type of Insurance Needed(Required) Auto Insurance Home Insurance (Dwelling, Apartment, Rented, Owned) Cabin Insurance Rental Properties Recreational Vehicles (ATVs, Snowmobile, Golf Carts, etc.) Boats (Watercrafts, Jet Skis, Sail Boats, etc.) Farm/Ranch Insurance Earthquake Flood Life Insurance Health Insurance Umbrella Other/Not Listed How did you hear about us Referral Web Search Email Our Webpage Other # of Named Insureds(Required) 1 2 3 4 5 6 7 8 9 10 or more Typically 1 for individual, 2 for married# of Dependents (Children, Siblings, etc.)(Required) 0 1 2 3 4 5 6 7 8 or More # of Vehicles(Required) 0 1 2 3 4 5 6 7 8 9 or More # of Insured Locations(Required) 0 1 2 3 4 5 or More # of Household Members(Required) 1 2 3 4 5 6 7 8 or More everyone over 15 years old Household Members Household Members Tell us about the Household Members. H1 Primary Household MemberH1 Primary Household Name(Required) First Last H1 Date of Birth(Required) MM slash DD slash YYYY H1 Social Security # H1 Drivers License # Need if Vehicle insurance is requestedH1 Education High School Graduate Some College College Graduate Bachelors Masters PHD MD Used with underwriting for best pricingH1 Gender Male Female n/a H1 Years Driving Experience(Required)0, None11 Months or less1 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years or moreH1 Occupation H1 # of years at occupation 1 2 3 4 5 6 7 or more H1 Years in same industry 1 2 3 4 5 6 7 or more H1 Driver in Household Yes No n/a H1 Any Traffic Tickets 0 1 2 3 4 5 or More in last 5 yearsH1 Explain Tickets(Include description, date)H1 Any Accidents 0 1 2 3 4 5 or More For last 5 yearsH1 Explain Accidents (Description, Date, amount paid)H1 Primary Vehicle Driven (Year, Make, Model) H2 2nd Household MemberH2 Name First Last H2 Date of Birth MM slash DD slash YYYY H2 Social Security # H2 Drivers License # Need if Vehicle insurance is requestedH2 Education High School Graduate Some College College Graduate Bachelors Masters PHD MD Used with underwriting for best pricingH2 Gender Male Female n/a H2 Years Driving Experience(Required)0, None11 Months or less1 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years or moreH2 Occupation H2 # of years at occupation 1 2 3 4 5 6 7 or more H2 Years in same industry 1 2 3 4 5 6 7 or more H2 Driver in Household Yes No n/a H2 Any Traffic Tickets 0 1 2 3 4 5 or More in last 5 yearsH2 Explain Tickets(Include description, date)H2 Any Accidents 0 1 2 3 4 5 or More For last 5 yearsH2 Explain Accidents (Description, Date, amount paid)H2 Primary Vehicle Driven (Year, Make, Model) H3 Household Member 3H3 Name First Last H3 Date of Birth MM slash DD slash YYYY H3 Social Security # H3 Drivers License # Need if Vehicle insurance is requestedH3 Education High School Graduate Some College College Graduate Bachelors Masters PHD MD Used with underwriting for best pricingH3 Gender Male Female n/a H3 Years Driving Experience(Required)0, None11 Months or less1 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years or moreH3 Occupation H3 # of years at occupation 1 2 3 4 5 6 7 or more H3 Years in same industry 1 2 3 4 5 6 7 or more H3 Driver in Household Yes No n/a H3 Any Traffic Tickets 0 1 2 3 4 5 or More in last 5 yearsH3 Explain Tickets(Include description, date)H3 Any Accidents 0 1 2 3 4 5 or More For last 5 yearsH3 Explain Accidents (Description, Date, amount paid)H3 Primary Vehicle Driven (Year, Make, Model) H4 Household Member 4H4 Name First Last H4 Date of Birth MM slash DD slash YYYY H4 Social Security # H4 Drivers License # Need if Vehicle insurance is requestedH4 Education High School Graduate Some College College Graduate Bachelors Masters PHD MD Used with underwriting for best pricingH4 Gender Male Female n/a H4 Years Driving Experience(Required)0, None11 Months or less1 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years or moreH4 Occupation H4 # of years at occupation 1 2 3 4 5 6 7 or more H4 Years in same industry 1 2 3 4 5 6 7 or more H4 Driver in Household Yes No n/a H4 Any Traffic Tickets 0 1 2 3 4 5 or More in last 5 yearsH4 Explain Tickets(Include description, date)H4 Any Accidents 0 1 2 3 4 5 or More For last 5 yearsH4 Explain Accidents (Description, Date, amount paid)H4 Primary Vehicle Driven (Year, Make, Model) H5 Household Member 5 or MoreH5 List names, dates of birth, social security number, drivers license number, etc. Auto Insurance Auto Insurance Auto insurance can include liability and physical damage coverage. We use many different Carriers. Liability Limit Desired(Required) $100,000/$300,000/$100,000 $1,000,000 $2,000,000 $500,000 $250,000 Other # of Vehicles to Insure(Required) 1 2 3 4 5 or More # of Drivers to Insure(Required) 1 2 3 4 5 or More Vehicle 1Vehicle 1 Year(Required) Vehicle 1 Make(Required) Vehicle 1 Model(Required) Vehicle 1 VIN Vehicle 1 Coverage Desired Liability Comprehensive Coverage (Non-Collision) Collision Coverage Rental Reimbursement Towing $0 Glass Deductible Vehicle 1 Primary Driver Vehicle 1 Usage Pleasure Use Business Use Commute to Work Farm Use Retail Use Vehicle 1 Notes or RemarksVehicle 2Vehicle 2 Year(Required) Vehicle 2 Make(Required) Vehicle 2 Model(Required) Vehicle 2 VIN Vehicle 2 Coverage Desired Liability Comprehensive Coverage (Non-Collision) Collision Coverage Rental Reimbursement Towing $0 Glass Deductible Vehicle 2 Primary Driver Vehicle 2 Usage Pleasure Use Business Use Commute to Work Farm Use Retail Use Vehicle 2 Notes or RemarksVehicle 3Vehicle 3 Year(Required) Vehicle 3 Make(Required) Vehicle 3 Model(Required) Vehicle 3 VIN Vehicle 3 Coverage Desired Liability Comprehensive Coverage (Non-Collision) Collision Coverage Rental Reimbursement Towing $0 Glass Deductible Vehicle 3 Primary Driver Vehicle 3 Usage Pleasure Use Business Use Commute to Work Farm Use Retail Use Vehicle 3 Notes or RemarksVehicle 4Vehicle 4 Year(Required) Vehicle 4 Make(Required) Vehicle 4 Model(Required) Vehicle 4 VIN Vehicle 4 Coverage Desired Liability Comprehensive Coverage (Non-Collision) Collision Coverage Rental Reimbursement Towing $0 Glass Deductible Vehicle 4 Primary Driver Vehicle 4 Usage Pleasure Use Business Use Commute to Work Farm Use Retail Use Vehicle 4 Notes or RemarksVehicle 5Vehicle 5 - Year Make Model VIN Usage - List more vehicles here.Drivers Drivers Drivers Driver Details All Drivers are listed There are no Accidents or Vehicle Claims (3 Years) All Vehicles are garaged at primary address Driver 1Same as Household Member 1 (H1)(Required) Same as Household Member 1 (H1) Different (I'll enter info in for driver 1) Driver 1 Name(Required) First Last Driver 1 Date of Birth(Required) MM slash DD slash YYYY Driver 1 Gender(Required) Male Female n/a Driver 1 Martial Status(Required) Single Married Widowed Divorced Separated n/a Driver 1 Social Security # Driver 1 Drivers License State(Required) Driver 1 Drivers License #(Required) Driver 1 Primary Vehicle Driven Driver 1 All Tickets and Accidents in last 5 yearsInclude Date, description, amount paid, State none if no tickets or accidents in 5 years.Driver 2Same as Household Member 2 (H2)(Required) Same as Household Member 2 (H2) Different (I'll enter info in for driver 2) Driver 2 Name(Required) First Last Driver 2 Date of Birth(Required) MM slash DD slash YYYY Driver 2 Gender(Required) Male Female n/a Driver 2 Martial Status(Required) Single Married Widowed Divorced Separated n/a Driver 2 Social Security # Driver 2 Drivers License State(Required) Driver 2 Drivers License #(Required) Driver 2 Primary Vehicle Driven Driver 2 All Tickets and Accidents in last 5 yearsInclude Date, description, amount paid, State none if no tickets or accidents in 5 years.Driver 3Same as Household Member 3 (H3)(Required) Same as Household Member 3 (H3) Different (I'll enter info in for driver 3) Driver 3 Name(Required) First Last Driver 3 Date of Birth(Required) MM slash DD slash YYYY Driver 3 Gender(Required) Male Female n/a Driver 3 Martial Status(Required) Single Married Widowed Divorced Separated n/a Driver 3 Social Security # Driver 3 Drivers License State(Required) Driver 3 Drivers License #(Required) Driver 3 Primary Vehicle Driven Driver 3 All Tickets and Accidents in last 5 yearsInclude Date, description, amount paid, State none if no tickets or accidents in 5 years.Driver 4Same as Household Member 4 (H4)(Required) Same as Household Member 4 (H4) Different (I'll enter info in for driver 4) Driver 4 Name(Required) First Last Driver 4 Date of Birth(Required) MM slash DD slash YYYY Driver 4 Gender(Required) Male Female n/a Driver 4 Martial Status(Required) Single Married Widowed Divorced Separated n/a Driver 4 Social Security # Driver 4 Drivers License State(Required) Driver 4 Drivers License #(Required) Driver 4 Primary Vehicle Driven Driver 4 All Tickets and Accidents in last 5 yearsInclude Date, description, amount paid, State none if no tickets or accidents in 5 years.Driver 5 or MoreList all drivers, names, dates of birth, primary vehicle driven, Social Security #, Drivers License #, etc. Home Insurance Coverage Home Insurance Home Insurance # of Locations (Homes, Cabins, Rental Units) 0 1 2 3 4 or More Locations Location 1 (L1)L1 Premises Status(Required) House Owner Tenant Leasee L1 # of Buildings(Required) 1 Building 2 Buildings 3 Buildings L1 Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code L1 Year Built L1 Construction Type Frame Concrete Brick L1 Exterior Material Wood Siding Vinyl Siding Brick Concrete Metal L1 Square Footage of business L1 Number of Stories 1 2 3 4 5 or More L1 Building Coverage Amount Desired L1 Contents Coverage Amount Desired L1 Age of Wiring (Update Date) L1 Age of Roof(Update Date) L1 Age of Plumbing (Update Date) L1 Age of Heating (Update Date) L1 Safety Features Local Fire Alarm (Smoke Detectors) Central Fire Alarm (Calls Fire Department) Local Burglar Alarm Central Fire Alarm (Calls Fire Department) Sprinklers Guards Alternate Water Supply Back Up Generators L1 Risks Animals Swimming Pool Home Based Business Activity Auto Repair Habitational (Renters) Daycare Business (In home) L1 Endorsements (Additional Coverages) Water and Sewer Backup Unscheduled Personal Property (inexpensive jewelry, etc.) Refrigerated Food Products Loss Assessment (claim assessed by associations) Cyber Coverage Fire Department Service Charge Credit Card Forgery Money Gold and Silver Securities Deeds, Silver Firearms, Equipment Silverware, Goldware Rental Property Timeshare Coverage Farm Coverage Location 2 (L2)L2 Premises Status(Required) House Owner Tenant Leasee L2 # of Buildings(Required) 1 Building 2 Buildings 3 Buildings L2 Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code L2 Year Built L2 Construction Type Frame Concrete Brick L2 Exterior Material Wood Siding Vinyl Siding Brick Concrete Metal L2 Square Footage of business L2 Number of Stories 1 2 3 4 5 or More L2 Building Coverage Amount Desired L2 Contents Coverage Amount Desired L2 Age of Wiring (Update Date) L2 Age of Roof(Update Date) L2 Age of Plumbing (Update Date) L2 Age of Heating (Update Date) L2 Safety Features Local Fire Alarm (Smoke Detectors) Central Fire Alarm (Calls Fire Department) Local Burglar Alarm Central Fire Alarm (Calls Fire Department) Sprinklers Guards Alternate Water Supply Back Up Generators L2 Risks Animals Swimming Pool Home Based Business Activity Auto Repair Habitational (Renters) Daycare Business (In home) L2 Endorsements (Additional Coverages) Water and Sewer Backup Unscheduled Personal Property (inexpensive jewelry, etc.) Refrigerated Food Products Loss Assessment (claim assessed by associations) Cyber Coverage Fire Department Service Charge Credit Card Forgery Money Gold and Silver Securities Deeds, Silver Firearms, Equipment Silverware, Goldware Rental Property Timeshare Coverage Farm Coverage Location 3 (L3)L3 Premises Status(Required) House Owner Tenant Leasee L3 # of Buildings(Required) 1 Building 2 Buildings 3 Buildings L3 Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code L3 Year Built L3 Construction Type Frame Concrete Brick L3 Exterior Material Wood Siding Vinyl Siding Brick Concrete Metal L3 Square Footage of business L3 Number of Stories 1 2 3 4 5 or More L3 Building Coverage Amount Desired L3 Contents Coverage Amount Desired L3 Age of Wiring (Update Date) L3 Age of Roof(Update Date) L3 Age of Plumbing (Update Date) L3 Age of Heating (Update Date) L3 Safety Features Local Fire Alarm (Smoke Detectors) Central Fire Alarm (Calls Fire Department) Local Burglar Alarm Central Fire Alarm (Calls Fire Department) Sprinklers Guards Alternate Water Supply Back Up Generators L3 Risks Animals Swimming Pool Home Based Business Activity Auto Repair Habitational (Renters) Daycare Business (In home) L3 Endorsements (Additional Coverages) Water and Sewer Backup Unscheduled Personal Property (inexpensive jewelry, etc.) Refrigerated Food Products Loss Assessment (claim assessed by associations) Cyber Coverage Fire Department Service Charge Credit Card Forgery Money Gold and Silver Securities Deeds, Silver Firearms, Equipment Silverware, Goldware Rental Property Timeshare Coverage Farm Coverage Location 4 or MorePlease list all other locations with address, building detailsCabin Insurance Cabin Insurance Cabin insurance will include liability and physical damage for underlying coverage. We use many different Carriers. Please Provide details of cabin, address, building description, year built, how to insure for etc.(Required)Umbrella Umbrella Insurance Umbrella insurance will include liability for underlying coverage. We use many different Carriers. Amount of Coverage $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 Other Important Items or Risks to be coveredRental Properties Rental Property Insurance Rental Property insurance will include liability and physical damage for underlying coverage. We use many different Carriers. Please Provide details of rental properties, address, building description, year built, how to insure for etc.(Required) Recreational Vehicles Recreational Vehicles Insurance Recreational Vehicles insurance will include liability and physical damage for underlying coverage. We use many different Carriers. Please Provide details of recreational vehicles, year manufacturer model, value, etc.(Required)Boats (Watercrafts) Boat Insurance Boats insurance will include liability and physical damage for underlying coverage. We use many different Carriers. Please Provide details of boats, year manufacturer model, value, motor size, etc.(Required) Farm Ranch Insurance Farm and Ranch Insurance Farm and Ranch insurance will include liability and physical damage for underlying coverage. We use many different Carriers. Please Provide details of farming and ranching, type of farming, equipment, etc.(Required) Earthquake Earthquake Insurance Earthquake insurance will physical damage for covered properties. We use many different Carriers. Please Provide details of locations that need earthquake coverage(Required)Flood Insurance Flood Insurance Flood insurance will physical damage for covered properties. We use many different Carriers. Please Provide details of locations that need earthquake coverage(Required) Life Insurance Life Insurance Life insurance will provide a death benefit for covered household members. We use many different Carriers. List all household members that require life insurance and desired amount(Required)Health Insurance Health Insurance Health insurance will provide a death benefit for covered household members. We use many different Carriers. List all household members that require health insurance(Required) Other Insurance Needs Other Insurance Other Insurance List the other insurance needs Δ
