New Business Questionnaire - The Seltzer Group Skip to main content
The Seltzer Group
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*NEW* Free Quote Questionnaire

Step 1 of 13

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  • Instructions

    Thank you for taking the time to review your current coverages with us, we are excited to discuss our services with you! To make it as convenient as possible, we have developed this online form. Please do your best to fill out all information in its entirety. If all details are not available at time of completion, please submit all known information in a timely manner. If you have any questions or prefer to complete this questionnaire with us directly, please call us at 888-366-1000.
  • Please choose a name from the list. If no one referred you, please select "OTHER".
    PLEASE REMEMBER THAT WE CAN OFFER ADDITIONAL DISCOUNTS WHEN MORE THAN ONE POLICY IS PACKAGED TOGETHER!

  • Insured's Information

  • Insurance Information

  • Home Underwriting Questions

    Please answer each question. If the answer is "YES", please provide details.

  • Home Property and Construction

  • Wall Finish Types

    Please select % of each type of wall finish in your home. Total value should equal 100%.
  • Please enter a number from 0 to 100.
  • Please enter a number from 0 to 100.
  • Please enter a number from 0 to 100.
  • Please enter a number from 0 to 100.
  • Please enter a number from 0 to 100.

  • Flooring Types

    Please select % of each type of flooring in your home. Total value should equal 100%.
  • Please enter a number from 0 to 100.
  • Please enter a number from 0 to 100.
  • Please enter a number from 0 to 100.
  • Please enter a number from 0 to 100.
  • Please enter a number from 0 to 100.

  • Do you have any of the following in your home?

    Please select quantity.

  • Additional property questions:

  • Auto Drivers Information - Driver 1

    We will provide the ability to enter up to 4 drivers in the same household. In the event there are more drivers, please notify us when we review your application.

  • Auto Drivers Information - Driver 2

  • Auto Drivers Information - Driver 3

  • Auto Drivers Information - Driver 4

  • Additional Details

  • Auto Vehicle Information - Vehicle 1

    We will provide the ability to enter up to 4 vehicles in the same household. In the event there are more vehicles, please notify us when we review your application.
  • Please enter a number from 1900 to 2050.
  • Please enter a number from 0 to 500.
  • Please enter a number from 0 to 7.

  • Auto Vehicle Information - Vehicle 2

  • Please enter a number from 1900 to 2050.
  • Please enter a number from 0 to 500.
  • Please enter a number from 0 to 7.

  • Auto Vehicle Information - Vehicle 3

  • Please enter a number from 1900 to 2050.
  • Please enter a number from 0 to 500.
  • Please enter a number from 0 to 7.

  • Auto Vehicle Information - Vehicle 4

  • Please enter a number from 1900 to 2050.
  • Please enter a number from 0 to 500.
  • Please enter a number from 0 to 7.

  • Current Auto Coverage Information

    Please answer the following questions in relation to your CURRENT policy and coverage limits.
  • NOTE: Split limit liability coverage divides the coverage limits up over 3 areas - one amount for bodily injury per person, one amount for bodily injury for the accident and one limit for property damage for the incident. Single limit liability auto insurance coverage provides one limit cap over an entire accident incident.

  • First Party Benefits

    Please answer the following questions in relation to your CURRENT policy and coverage limits.
  • NOTE: First Party Benefits have individual limits for Medical, Work Loss, Accidental and Funeral limits and Combination Package Benefits have a combined limit for all.

  • Uninsured/Underinsured Motorists

    Please answer the following questions in relation to your CURRENT policy and coverage limits.
  • NOTE: Split limit liability coverage divides the coverage limits up over 3 areas - one amount for bodily injury per person, one amount for bodily injury for the accident and one limit for property damage for the incident. Single limit liability auto insurance coverage provides one limit cap over an entire accident incident.

  • Physical Damage Coverage

    Please answer the following questions in relation to your CURRENT policy and coverage limits. If no current policy is in place, please select options you are interested in for new policy.

  • Vehicle 1

  • Vehicle 2

  • Vehicle 3

  • Vehicle 4

  • Personal Umbrella

    Please answer the following questions to the best of your ability.

  • Life Questions

    Please answer the following questions to the best of your ability.

  • Life Questions for Spouse or Significant Other

    Please answer the following questions to the best of your ability.
  • Drop files here or

  • Remarks and Comments

  • This field is for validation purposes and should be left unchanged.
The next step is easy, call 888-366-1000 Or, Contact Us

Our Approach

At The Seltzer Group, we focus on you. Our team is here to listen to and champion your unique needs by creating a custom insurance solution that balances risk, coverage and value.

Our philosophy is not about simply pushing the lowest-priced policies to our customers as fast as possible; we have dedicated ourselves to becoming true problem solvers.

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Our Mission

We strive to provide excellent insurance and related services to individuals, institutions and businesses.

We know that keeping what’s important to you protected brings peace-of-mind. At the end of that day, that’s our main goal.

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  • Who We Are
    • Our Story
    • Our Partners
    • The Power of Keystone
    • Community Involvement
    • Meet Our Team
    • Join Us!
    • Richard I Hart Insurance Agency
    • Spring Ridge Insurance
  • Our Unique Process
    • Our Process
    • Seltzer Strong Values
    • For Business
    • Industry Specialties
    • For People
    • Unique Risk Processes
      • Workers’ Compensation Process
      • Captive Programs
      • Human Resources
      • Safety Services
      • Claims Services
  • Self-Service
  • News & Insights
    • Agency News
    • Newsletters
    • Webinars & Coffee Talks
    • Tidbits & Tricks
    • Join Our Mailing List
  • Testimonials
  • Contact
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