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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.
Who referred you to this form today?
*
Please choose a name from the list. If no one referred you, please select "OTHER".
Amy K.
Berni
Bryan
Chad
Cherie
Cheryl
Chris
Emily
Heidi W.
Jackie H.
Jamie
Jesse
Jina
Joanne D.
Joe C.
Joan M.
Joann F.
Josh
Justine
Kaliyah H.
Laci
Lisa
Marie
MaryAnn
Nichole
Sarah L.
Sean M.
Tina S.
OTHER
How did you hear about Seltzer Group Partners
Someone referred me
Former client
Ad
Social Media (Facebook, LinkedIn, etc.)
Radio
Other
What coverage(s) are you interested in today? Check all that apply.
*
Select All
Home
Auto
Umbrella
Life
PLEASE REMEMBER THAT WE CAN OFFER ADDITIONAL DISCOUNTS WHEN MORE THAN ONE POLICY IS PACKAGED TOGETHER!
Insured's Information
Name
*
First
Last
Phone
*
Cell Phone
Work Phone
Marital Status
Single
Married
Divorced
Widowed
Email
*
Occupation
*
Employer
Current Mailing Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Property Address
*
Check if property address is the same as mailing address.
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Is current residence rented or owned?
*
Rented
Owned
How long have you lived at this address? (If less than 5 years, please list previous address below.)
Previous Address (If current residence is less than 5 years)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Do you live in a Gated Community or belong to a Homeowner's Association?
*
Yes
No
Please list any additional comments or concerns you have regarding the above questions, here:
Insurance Information
Current or former Insurance Carrier?
*
How long insured:
Expiration Date of Policy
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Current Premium:
Is your current policy being cancelled or non-renewed? (If "YES", please explain why below.)
Yes
No
Please provide additional details:
Preferred frequency of payment:
Monthly
Quarterly
Semi-Annual
Annually
Preferred method of payment:
Check
Credit/Debit Card
Automatic bank account deduction (EFT)
Please list any additional comments or concerns you have regarding the above questions, here:
Home Underwriting Questions
Please answer each question. If the answer is "YES", please provide details.
Have there been any losses in the past 5 years?
*
Yes
No
Please provide additional details:
Do you own and occupy this house?
*
Yes
No
Is there a mortgage on the home?
*
Yes
No
Is the insurance escrowed?
Yes
No
Are there any borders or tenants?
*
Yes
No
Please provide additional details:
Is there any business conducted on the property?
*
Yes
No
Please provide additional details:
Do you do any home sharing (HomeAway, VRBO, etc.)?
*
Yes
No
Please list the number of bedrooms in the home:
*
Is the home attached? (If "yes", please list number of homes in row below)
*
Yes
No
Number of homes in the row:
Is there a trampoline on the property?
*
Yes
No
Is there a pool on the property?
*
Yes
No
Is there a removable ladder?
*
Yes
No
Is there a slide?
*
Yes
No
Is there a diving board?
*
Yes
No
Is the pool fenced in?
*
Yes
No
Is there a locked gate on the fence?
Yes
No
Do you own any pets?
*
Yes
No
Please explain what type of pets. If you have any dogs, please list their breed.
Have your animals ever attacked anyone or shown aggressive behavior?
*
Yes
No
Please provide additional details:
Is there any asbestos, EFIS or DRYVIT siding?
*
Yes
No
Please provide additional details:
Do you own any other property?
*
Yes
No
Please provide additional details:
Do you have any jewelry stored on the property?
*
Yes
No
Do you have any furs stored on the property?
*
Yes
No
Do you have any guns stored on the property?
*
Yes
No
Do you have any collectables stored on the property?
*
Yes
No
If you have any other expensive items stored on the property, please provide an itemized list and approximate values:
Do you have any of the following recreational vehicles? (Please check all that apply)
Motorcycles
Boats
ATVs
Snowmobiles
Golf Carts
Other
Please provide details of above selected recreational vehicles (make, model, year, etc.)
How is the home deeded?
*
How many acres are part of this property?
*
Approximately how many feet to the nearest fire hydrant?
*
If no hydrants, can the home be seen by at least 5 other homes year-round?
Yes
No
Approximately how many miles to the nearest fire company?
*
Fire District or Township in which home is located:
*
Please list any additions which have been completed on the home since the purchase:
Please list any additional comments or concerns you have regarding the above questions, here:
Home Property and Construction
Year home was built:
*
Type of home (bi-level, ranch, etc.):
*
Is the home manufactured, mobile or built from ground up (please describe):
*
Number of stories:
*
Number of bathrooms:
*
How many families residing in home:
*
Do any occupants in the home smoke?
*
Yes
No
Square footage (of living area):
*
Foundation type:
*
Basement square footage (finished living space):
Primary exterior type:
*
Please list any additional comments or concerns you have regarding the above questions, here:
Wall Finish Types
Please select % of each type of wall finish in your home. Total value should equal 100%.
Paint
*
Please enter a number from
0
to
100
.
Wallpaper
*
Please enter a number from
0
to
100
.
Paneling
*
Please enter a number from
0
to
100
.
Tile
*
Please enter a number from
0
to
100
.
Wood
*
Please enter a number from
0
to
100
.
Please list any additional comments or concerns you have regarding the above questions, here:
Flooring Types
Please select % of each type of flooring in your home. Total value should equal 100%.
Carpet
*
Please enter a number from
0
to
100
.
Vinyl:
*
Please enter a number from
0
to
100
.
Hardwood:
*
Please enter a number from
0
to
100
.
Tile:
*
Please enter a number from
0
to
100
.
Marble:
*
Please enter a number from
0
to
100
.
Please list any other types of flooring in the home and the % they make up:
Please list any additional comments or concerns you have regarding the above questions, here:
Do you have any of the following in your home?
Please select quantity.
Bow windows (if yes, list quantity, if no, type "none") :
*
French doors (if yes, list quantity, if no, type "none") :
*
Sliding glass doors (if yes, list quantity, if no, type "none") :
*
Skylights (if yes, list quantity, if no, type "none") :
*
Fence:
*
Yes
No
Porches or decks:
*
Yes
No
Please list the quantity and description of the porches/decks:
Please list any additional comments or concerns you have regarding the above questions, here:
Additional property questions:
Does the property have any knob-and-tube or aluminum wiring?
*
Yes
No
Please describe what form of wiring is in the home:
Are there any sheds on the property?
*
Yes
No
Please list quantity and square footage of each:
Please list the exterior siding:
Does it have electricity?
*
Yes
No
Does it have heat?
*
Yes
No
Please list the source of heat:
Do you have a garage/carport?
*
Yes
No
Is the garage/carport:
attached to the home
detached from the home
I have multiple, at least one is attached and at least one is detached
Please list quantity and square footage of each:
Please list the exterior siding:
Does it have electric?
*
Yes
No
Does it have heat?
*
Yes
No
Please list the source of heat:
Please select any recreational structures that are located on the property: (If "other" is selected, please describe structure below.)
*
Zip Line(s)
Skateboard or bike ramp(s)
Treehouse(s)
Other
None of the above
Please provide additional details:
Do you have any other structures on the property?
*
Yes
No
Please list details and square footage of each:
Please list exterior siding of other structures:
Does it have electric?
*
Yes
No
Does it have heat?
*
Yes
No
Please list the source of heat:
Does the property have underground oil or gas tanks?
*
Yes
No
Does the property have any underground service lines?
*
Yes
No
What type of heat do you have? (Oil, coal, electric, etc.)
*
When, if ever, was your heating system last updated? Please provide details of update, repair or replacement and month/year of update, repair or replacement.
Does the home have a coal stove, wood burning stove or supplemental heat source?
*
Yes
No
Please describe:
Was it professionally installed?
*
Yes
No
Where is it located?
*
What is the flooring type under the unit?
*
What is the wall covered with behind the unit?
*
Does the unit have its own chimney?
*
Yes
No
What type of plumbing do you have? (Copper, PVC, Pex, Combination, etc.)
*
When, if ever, was your plumbing system last updated? Please provide details of update, repair or replacement and month/year of update, repair or replacement.
What type of electric do you have? If circuit breaker, how many amps? (Knob & Tube, fuse box, circuit breaker, etc.)
*
When, if ever, was your electrical system last updated? Please provide details of update, repair or replacement and month/year of update, repair or replacement.
Do you have central air?
*
Yes
No
When, if ever, was your central air system last repaired or updated? (Please specify month/year of repairs or updates as well as details of repairs or updates.)
Do you have any solar panels on your roof?
*
Yes
No
Have you performed any updates on the roof? (If "yes", please provide details below.)
*
Yes
No
Please provide the type of roof that was updated (peaked, slight pitch, flat, etc.) and material of roof (shingle, asphalt, tar, metal, etc.):
Please select any you may have:
Monitored central fire alarm
Central monitored burglar alarm
Smoke detectors
Dead bolt locks
Fire extinguishers
CO2 detectors
Do you own any drones?
*
Yes
No
Please list any additional comments or concerns you have regarding the above questions, here:
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.
Name:
First
Last
Date of birth:
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Driver's License Number:
Date Licensed:
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Marital Status:
Single
Married
Divorced
Widowed
Sex:
Male
Female
Accidents or violations (please describe below):
Please select any or all that apply:
Student living more than 100 miles away
Good Student
Driver Training
Accident prevention course?
Yes
No
Date completed:
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Highest level of education:
Middle School
High School Diploma/GED
Some College
Associates Degree
Bachelors Degree
Masters Degree
Doctorate
Do you do any ride-sharing (Uber, Lyft, etc.) or other delivery services?
*
Yes
No
Please list any additional comments or concerns you have regarding the above questions, here:
Are there any more drivers in the household?
*
Yes
No
Auto Drivers Information - Driver 2
Name:
First
Last
Date of birth:
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Driver's License Number:
Date Licensed:
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Marital Status:
Single
Married
Divorced
Widowed
Sex:
Male
Female
Accidents or violations (please describe below):
Please select any or all that apply:
Student living more than 100 miles away
Good Student
Driver Training
Accident prevention course?
Yes
No
Date completed:
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Does this driver do any ride-sharing (Uber, Lyft, etc.) or other delivery services?
*
Yes
No
Please list any additional comments or concerns you have regarding the above questions, here:
Are there any more drivers in the household?
*
Yes
No
Auto Drivers Information - Driver 3
Name:
First
Last
Date of birth:
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Driver's License Number:
Date Licensed:
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Marital Status:
Single
Married
Divorced
Widowed
Sex:
Male
Female
Accidents or violations (please describe below):
Please select any or all that apply:
Student living more than 100 miles away
Good Student
Driver Training
Accident prevention course?
Yes
No
Date completed:
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Does this driver do any ride-sharing (Uber, Lyft, etc.) or other delivery services?
*
Yes
No
Please list any additional comments or concerns you have regarding the above questions, here:
Are there any more drivers in the household?
*
Yes
No
Auto Drivers Information - Driver 4
Name:
First
Last
Date of birth:
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Driver's License Number:
Date Licensed:
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Marital Status:
Single
Married
Divorced
Widowed
Sex:
Male
Female
Accidents or violations (please describe below):
Please select any or all that apply:
Student living more than 100 miles away
Good Student
Driver Training
Accident prevention course?
Yes
No
Date completed:
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Does this driver do any ride-sharing (Uber, Lyft, etc.) or other delivery services?
*
Yes
No
Please list any additional comments or concerns you have regarding the above questions, here:
Additional Details
Do you have access to a company vehicle on a full-time basis?
*
Yes
No
Please provide vehicle details:
Are there any additional drivers in the household with their own insurance or vehicle? (If yes, please describe below.)
*
Yes
No
Please provide additional drivers names, dates of birth and vehicle information:
Please list any additional comments or concerns you have regarding the above questions, here:
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.
Year:
Please enter a number from
1900
to
2050
.
Make:
Model:
VIN Number:
Driver Name:
First
Last
Vehicle usage (work, recreational, etc.):
Miles to work (one way):
Please enter a number from
0
to
500
.
Days per week:
Please enter a number from
0
to
7
.
Current mileage on the vehicle:
Annual mileage of vehicle:
Check all that apply:
Passive Restraint
Anti-theft
ABS
Airbags
Is there a lienholder on the vehicle? (If "Yes", please list below.)
Yes
No
Please list the lienholder:
Please list the name(s) on the title:
Where is the vehicle parked/garaged on a daily basis?
Please list any additional comments or concerns you have regarding the above questions, here:
Do you have any other vehicles?
*
Yes
No
Auto Vehicle Information - Vehicle 2
Year:
Please enter a number from
1900
to
2050
.
Make:
Model:
VIN Number:
Driver Name:
First
Last
Vehicle usage (work, recreational, etc.):
Miles to work (one way):
Please enter a number from
0
to
500
.
Days per week:
Please enter a number from
0
to
7
.
Current mileage on the vehicle:
Annual mileage of vehicle:
Check all that apply:
Passive Restraint
Anti-theft
ABS
Airbags
Is there a lienholder on the vehicle? (If "Yes", please list below.)
Yes
No
Please list the lienholder:
Please list the name(s) on the title:
Where is the vehicle parked/garaged on a daily basis?
Please list any additional comments or concerns you have regarding the above questions, here:
Do you have any other vehicles?
*
Yes
No
Auto Vehicle Information - Vehicle 3
Year:
Please enter a number from
1900
to
2050
.
Make:
Model:
VIN Number:
Driver Name:
First
Last
Vehicle usage (work, recreational, etc.):
Miles to work (one way):
Please enter a number from
0
to
500
.
Days per week:
Please enter a number from
0
to
7
.
Current mileage on the vehicle:
Annual mileage of vehicle:
Check all that apply:
Passive Restraint
Anti-theft
ABS
Airbags
Is there a lienholder on the vehicle? (If "Yes", please list below.)
Yes
No
Please list the lienholder:
Please list the name(s) on the title:
Where is the vehicle parked/garaged on a daily basis?
Please list any additional comments or concerns you have regarding the above questions, here:
Do you have any other vehicles?
*
Yes
No
Auto Vehicle Information - Vehicle 4
Year:
Please enter a number from
1900
to
2050
.
Make:
Model:
Driver Name:
First
Last
VIN Number:
Vehicle usage (work, recreational, etc.):
Miles to work (one way):
Please enter a number from
0
to
500
.
Days per week:
Please enter a number from
0
to
7
.
Current mileage on the vehicle:
Annual mileage of vehicle:
Check all that apply:
Passive Restraint
Anti-theft
ABS
Airbags
Is there a lienholder on the vehicle? (If "Yes", please list below.)
Yes
No
Please list the lienholder:
Please list the name(s) on the title:
Where is the vehicle parked/garaged on a daily basis?
Please list any additional comments or concerns you have regarding the above questions, here:
Current Auto Coverage Information
Please answer the following questions in relation to your CURRENT policy and coverage limits.
What form of coverage do you have?
*
Split Limit Liability (Bodily Injury & Property Limits)
Combined Single Limit (CSL)
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.
Bodily Injury Liability:
15,000/30,000
25,000/50,000
50,000/100,000
100,000/300,000
250,000/500,000
Property Damage Liability:
5,000
50,000
100,000
250,000
Single Limit Liability:
100,000
300,0000
500,000
1,000,000
Tort Option:
Full
Limited
Please list any additional comments or concerns you have regarding the above questions, here:
First Party Benefits
Please answer the following questions in relation to your CURRENT policy and coverage limits.
What form of coverage do you have for first party benefits?
*
First Party Benefits (FPB)
First Party Benefit - Combination Package Benefit (FPB CPB)
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.
Medical Benefit
10,000
25,000
50,000
100,0000
Work Loss Benefits
1,000/5,000
1,000/15,000
1,500/25,000
2,500/50,000
None
Funeral Benefits
1,500
2,500
None
Accidental Benefits
5,000
10,000
15,000
25,000
None
Combination First Party Benefits
177,500
277,000
Extraordinary Medical Benefits
None
1,000,000
Please list any additional comments or concerns you have regarding the above questions, here:
Uninsured/Underinsured Motorists
Please answer the following questions in relation to your CURRENT policy and coverage limits.
What form of coverage do you have for uninsured/underinsured motorists?
*
Split Limit Liability (Bodily Injury & Property Limits)
Combined Single Limit (CSL)
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.
Bodily Injury Liability:
15,000/30,000
25,000/50,000
50,000/100,000
100,000/300,000
250,000/500,000
Single Limit Liability:
100,000
300,0000
500,000
1,000,000
Stack Option:
Stacked
Non stacked
Please list any additional comments or concerns you have regarding the above questions, here:
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
Comprehensive:
*
0
50
100
250
500
1,000
Collision:
*
0
50
100
250
500
1,000
Rental Expense/Transportation Expense:
*
None
30/900
40/1,200
50/1,500
Full Glass Coverage:
*
Yes
No
Accident Forgiveness:
*
Yes
No
Gap Coverage:
*
Yes
No
Repair/Replacement Cost Coverage
Yes
No
Towing & Labor:
*
Yes
No
Total Premium:
Please list any additional comments or concerns you have regarding the above questions, here:
Are there any other insurable vehicles registered to the household?
*
Yes
No
Vehicle 2
Comprehensive:
0
50
100
250
500
1,000
Collision:
0
50
100
250
500
1,000
Rental Expense:
30/900
40/1,200
50/1,500
Full Glass Coverage:
*
Yes
No
Accident Forgiveness:
*
Yes
No
Gap Coverage:
*
Yes
No
Repair/Replacement Cost Coverage
Yes
No
Towing & Labor:
*
Yes
No
Total Premium:
Please list any additional comments or concerns you have regarding the above questions, here:
Are there any other insurable vehicles registered to the household?
*
Yes
No
Vehicle 3
Comprehensive:
0
50
100
250
500
1,000
Collision:
0
50
100
250
500
1,000
Rental Expense:
30/900
40/1,200
50/1,500
Full Glass Coverage:
*
Yes
No
Accident Forgiveness:
*
Yes
No
Gap Coverage:
*
Yes
No
Repair/Replacement Cost Coverage
Yes
No
Towing & Labor:
*
Yes
No
Total Premium:
Please list any additional comments or concerns you have regarding the above questions, here:
Are there any other insurable vehicles registered to the household?
*
Yes
No
Vehicle 4
Comprehensive:
0
50
100
250
500
1,000
Collision:
0
50
100
250
500
1,000
Rental Expense:
30/900
40/1,200
50/1,500
Full Glass Coverage:
*
Yes
No
Accident Forgiveness:
*
Yes
No
Gap Coverage:
*
Yes
No
Repair/Replacement Cost Coverage
Yes
No
Towing & Labor:
*
Yes
No
Total Premium:
Please list any additional comments or concerns you have regarding the above questions, here:
Personal Umbrella
Please answer the following questions to the best of your ability.
Do you have any real estate, vehicles, watercrafts or aircrafts, owned, hired, leased or regularly used, not covered by primary policies? (If "yes", please explain)
*
Yes
No
Please provide additional details:
Do you engage in any type of farming operations? (If "yes", please explain)
Yes
No
Please provide additional details:
Do you hold any non-compensated positions? (If "yes", please explain)
*
Yes
No
Third Choice
Please provide additional details:
Is there any non-owned property exceeding $1,000 in value in your care, custody or control? (If "yes", please explain)
*
Yes
No
Please provide additional details:
Are there any business and/or professional activities included in your primary policies? (If "yes", please explain)
*
Yes
No
Please provide additional details:
Do any of your primary policies have reduced limits of liability or eliminate coverage for specific exposures? (If "yes", please explain)
*
Yes
No
Please provide additional details:
Do you have any pending litigation, court proceedings or judgements? (If "yes", please explain)
*
Yes
No
Please provide additional details:
Have you had any coverage declined, cancelled, or non-renewed during the last five (5) years? (If "yes", please explain)
*
Yes
No
Please provide additional details:
Has your insurance been transferred within the agency?
*
Yes
No
Please provide additional details:
Please list any additional comments or concerns you have regarding the above questions, here:
Life Questions
Please answer the following questions to the best of your ability.
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
*
Email
*
Date of Birth
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Height
*
Weight
*
Do you smoke? (If "yes", please provide additional details below)
*
Yes
No
Please indicate what you smoke and the frequency:
Before the age of 60, has either a sibling or parent had a history of cardiovascular disease or cancer? If "yes", please indicate "who" below.
*
Yes
No
Please indicate who:
Before age 60, has either parent died as a result of history of cardiovascular disease or cancer? If "yes", please indicate "who" below.
*
Yes
No
Please indicate who:
Please provide any health issues and family history below:
*
Please provide any medications and dosages taken on a regular basis below:
*
Please list any additional comments or concerns you have regarding the above questions, here:
Do you have a spouse or significant other?
*
Yes
No
Life Questions for Spouse or Significant Other
Please answer the following questions to the best of your ability.
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
*
Email
*
Date of Birth
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Height
*
Weight
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