Get a Quote Now! - Lee County Insurance

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Step 1 of 33

Are you Interested in Personal or Commercial Quotes:(Required)

Business Information:

Name of Business:(Required)

Name of Owner:(Required)

First Last

Owner Date of Birth:(Required)

MM slash DD slash YYYY

Phone Number:(Required)

Email Address:(Required)

Business Structure:(Required)

Year of Business Start:(Required)

Business Address(Required)

Street Address City State ZIP Code

What Business Coverage is Needed, Select ALL That Apply:(Required)

Commercial Auto Insurance

Business Property Insurance

Commercial Trucking Insurance

Cyber Liability Insurance

General Liability Insurance

Restaurant Insurance

Workers Compensation Insurance

Commercial Auto Insurance:

Storage Address:

Same as Business Address

Street Address City State ZIP Code

Number of Full-Time Employees:(Required)

Number of Part-Time Employees:(Required)

Radius of Operations in Miles:(Required)

Do you have a Commercial Auto Policy now without a 30 day Lapse in Coverage:(Required)

Previous Insurance Company:(Required)

Expiration Date:(Required)

MM slash DD slash YYYY

Insurance Policy Premium:(Required)

How many Permitted drivers will be Operating the Vehicle (Including Yourself):(Required)

Driver 1:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Driver 2:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Driver 3:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Driver 4:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Driver 5:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Driver 6:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Vehicles:

How many Vehicles Should be Added to your Business Auto Policy:(Required)

Vehicle 1:

Year:(Required)

Make:(Required)

Model(Required)

VIN:(Required)

Usage of the Vehicle:(Required)

Days per Week Used:(Required)

Vehicle 2:

Year:(Required)

Make:(Required)

Model(Required)

VIN:(Required)

Usage of the Vehicle:(Required)

Days per Week Used:(Required)

Vehicle 3:

Year:(Required)

Make:(Required)

Model(Required)

VIN:(Required)

Usage of the Vehicle:(Required)

Days per Week Used:(Required)

Vehicle 4:

Year:(Required)

Make:(Required)

Model(Required)

VIN:(Required)

Usage of the Vehicle:(Required)

Days per Week Used:(Required)

Vehicle 5:

Year:(Required)

Make:(Required)

Model(Required)

VIN:(Required)

Usage of the Vehicle:(Required)

Days per Week Used:(Required)

Vehicle 6:

Year:(Required)

Make:(Required)

Model(Required)

VIN:(Required)

Usage of the Vehicle:(Required)

Days per Week Used:(Required)

Business Property Insurance:

Services Provided:(Required)

Value of Property:(Required)

Desired Total Liability Amount:(Required)

Expected Sales for the Year:(Required)

Where does your Business Operate:(Required)

Have you had any Claims or Losses at this or any Other Addresses in the Past 5 years:(Required)

Value of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Detail of Incident:(Required)

Commercial Trucking Insurance:

Storage Address:

Same as Business Address

Street Address City State ZIP Code

Do you haul goods for:(Required)

What are you Hauling?:(Required)

Are any Hazard Placards ever Required:(Required)

What Products or Numbers:(Required)

Radius of Operations in Miles:(Required)

Does Operating Authority Require any of These Filings:(Required)

Do you have a USDOT # for the Vehicle or Trailer:(Required)

Is there any Permanently Attached Equipment:(Required)

USDOT Number on Vehicle or Trailer:(Required)

Approximate Value of all Attached Equipment:(Required)

Do any of your Vehicles Travel Across State Lines:(Required)

States Traveled:(Required)

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

Dist of Columbia

Florida

Georgia

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

Drivers:

How many Permitted drivers will be Operating the Vehicle (Including Yourself):(Required)

Driver 1:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License State:(Required)

Drivers License Number:(Required)

Any Claims or Violations:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Driver 2:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License State:(Required)

Drivers License Number:(Required)

Any Claims or Violations:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Driver 3:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License State:(Required)

Drivers License Number:(Required)

Any Claims or Violations:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Driver 4:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License State:(Required)

Drivers License Number:(Required)

Any Claims or Violations:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Cargo and Trailer Coverage:

Do you want Cargo Coverage:(Required)

What Limits:(Required)

What Deductible:(Required)

Would you like Trailer Interchange Coverage (If you would like Trailer Coverage, Please add it as a Vehicle Below):(Required)

What Deductible for Comp/Collision:(Required)

Vehicles:

How many Vehicles Should be Added to your Commercial Trucking Policy:(Required)

Vehicle 1:

Year:(Required)

Make:(Required)

Model(Required)

VIN:(Required)

Vehicle Usage:(Required)

Vehicle 2:

Year:(Required)

Make:(Required)

Model(Required)

VIN:(Required)

Vehicle Usage:(Required)

Vehicle 3:

Year:(Required)

Make:(Required)

Model(Required)

VIN:(Required)

Vehicle Usage:(Required)

Vehicle 4:

Year:(Required)

Make:(Required)

Model(Required)

VIN:(Required)

Vehicle Usage:(Required)

Cyber Liability Insurance:

Are you Currently Subject to:(Required)

PCI/DSS Compliance

HIPAA/HITECH Compliance

Neither

Do you use only chip-enabled cards or are your certified as PCI/DSS Compliant:(Required)

Do your Card Transactions Utilize End-to-End Encryption Technologies:(Required)

Do your Card Transactions Utilize Tokenization Technologies:(Required)

Are you Currently Compliant with HIPAA and HITECH Act Requirements:(Required)

Does your Business have Antivirus and/or Firewalls that are Updated at least Every Month:(Required)

Does your Business use 2FA/MFA for Access to Corporate Applications:(Required)

Is your Critical Business Information Backed-Up at least Once a Week:(Required)

Where is that Information Backed-Up to:(Required)

On-site

Offsite (Physical Storage)

Offsite (In the Cloud)

Data is Encrypted on:(Required)

Office Computers

Mobile Devices (Laptops, Cell Phones, Flash Drives, Tablets, etc.)

Networks

None

Is There one or more of these Controls in Place:(Required)

Critical Software Patching Procedures

Formal Cyber Incident Response Plan

VPN's when Accessing Connections on Work Devices

Multifactor Authentication on Systems, Networks, and Emails:

None

Do you or Anyone Affiliated with you know of any act, error, omission, or breach of duty that is Listed Below:(Required)

Network Intrusion

Denial of Service Attack

Unauthorized loss of Personally Identifiable Information in your Control

None

Has any Regulatory, Governmental, or Administrative action been Brought Against you due to your Handling of Sensitive Data(Required)

In the past five years, have you Experienced any claims related to a Data Breach, Extortion Threat, or any other Incident Involving a type of Fraud or Criminal Act:(Required)

Do you Currently rely on Cloud Computing, Software-as-a-Service, or any other Outsourced Computer Hosting for Revenue-Generating Operations:(Required)

Do you store, collect, or transmit any Customer Biometric Data:(Required)

Do you Provide any Consumer Products or Services:(Required)

General Liability Insurance:

Desired Liability Amount:(Required)

Expected Sales for the Year:(Required)

Years of Experience in the Business:(Required)

Number of Employees Total:(Required)

Number of Full-Time Employees:(Required)

Number of Part-Time Employees:(Required)

Do you Offer, Manufacture, or Distribute any Tangible Products?:(Required)

Do you do Design, Construction, Installation, or Repair of properties or products.(Required)

In the Past Three Years, have you had any type of Business Insurance Cancelled or Non-Renewed?:(Required)

Has your Business ever Operated without Insurance for 6 Months or More since the Start of your Business?(Required)

Do you have all Required Licenses or Permits:(Required)

Is all Work Performed in State:(Required)

Restaurant Insurance:

Type of Restaurant:(Required)

Opening Time of Operation:

Hours

Minutes

AM/PM

Closing Time of Operation:

Hours

Minutes

AM/PM

Gross Sales:(Required)

Food Sales:(Required)

Liquor Sales (If none, Please put a Zero in this Field):(Required)

Other Sales (If none, Please put a Zero in this Field):(Required)

Does the Applicant have Liquor Liability in Force:(Required)

Total Seating Capacity:(Required)

Is there any Table Service:(Required)

Does this Applicant rent out Spaces for Private Events, such as Weddings or Parties:(Required)

What is the Square Footage of the Rental Space:(Required)

Sales Generated from Renting the Space Out:(Required)

Is there a Grease Chute for the Grill:(Required)

How often is the Grease Chute Cleaned:(Required)

Are Deep fat Fryers Located more than 16" from an open Flame:(Required)

Do Deep Fryers have Thermostats or High Temperature Limits:(Required)

Is all Cooking Equipment Located Beneath an Approved Hood/Duct System:(Required)

How often are the Hood and Duct Cleaned:(Required)

Are the Hood and Duct Cleaned by a Firm:(Required)

Is there an Automatic Fuel Shut-Off:(Required)

Are there Portable Fire Extinguishers:(Required)

Number Tagged on the Extinguisher:(Required)

Date Extinguisher was Tagged:(Required)

MM slash DD slash YYYY

How Often are Refrigerator Compressors Inspected and Serviced:(Required)

Does the Restaurant have 2 means of Egress:(Required)

Is there a Fire Alarm:(Required)

Is there a Burglar Alarm:(Required)

Is there a Delivery Service:(Required)

Delivery Service Done by:(Required)

How is the Delivery Service Carried Out:(Required)

If Other, Please Explain Here:(Required)

If you Offer a Catering Service, is it:(Required)

What Preparation and Sanitation Procedures are Followed to Prevent Foodborne Illness:(Required)

Has the Applicant been Cited for any Health Code Violations:(Required)

Please Provide Citation or Incident Details:(Required)

What Controls are in Place to Avoid Over-Serving of Alcohol or Distribution to Minors:(Required)

Do Bartenders have TIPS(Training for Intervention Procedures) Training:(Required)

Has the Applicant been Cited for Violations of Beverage Laws:(Required)

Please Provide Citation or Incident Details:(Required)

Please Indicate any Entertainment Provided:(Required)

Live Music

Dance Floor

Karaoke

Arcade Games

Amusement Devices

Other

None of the Above

Please Provide Details about any Amusement Devices:(Required)

Please Provide Details of any Other Entertainment:(Required)

Is there a Valet Parking Service:(Required)

Is there a Separate Insurance for the Valet Parking Exposure:(Required)

Are any Bouncers/Security Personnel Employed or Contracted:(Required)

Are all Employees References Checked Prior to Hiring:(Required)

Workers Compensation Insurance:

Is there any Framing or Construction of new Buildings or Additional Jobs:(Required)

Estimated Gross Revenue that will be Earned for the next 12 Months:(Required)

Is there any new Construction in Multi-Home/Tract Home, Condo, Townhouse, Apartments, or Co-Ops:(Required)

Do you Perform any Exterior work above the height of 3 Stories:(Required)

Estimated Percentage of work Subcontracted out to Others:(Required)

Years of Industry Experience:(Required)

Do you Perform any Roofing work:(Required)

Total Amount of Desired Coverage:(Required)

Number of Full-Time Employees:(Required)

Number of Part-Time Employees:(Required)

Estimated Total Annual Payroll (Excluding Owners or Subcontractors):(Required)

Estimated Annual Payroll for the Business Owner for the next 12 Months:(Required)

Estimated Annual Payroll for the Subcontractors for the next 12 Months:(Required)

Personal Information:

First and Last Name:(Required)

First Last

Client Date of Birth:(Required)

MM slash DD slash YYYY

Cell Phone Number:(Required)

Email Address:(Required)

Gender:(Required)

Marital Status:(Required)

Highest Level of Education:(Required)

Relationship to Insured:(Required)

Would you Like to add a Co-Applicant?:(Required)

First and Last Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Cell Phone Number:(Required)

Email Address:(Required)

Gender:(Required)

Marital Status:(Required)

Highest Level of Education:(Required)

Relationship to Insured:(Required)

Mailing Address:(Required)

Street Address City State ZIP Code

Coverage:

What Personal Coverage is Needed. Select ALL That Apply:(Required)

Mobile/Manufactured Home Insurance

Auto Insurance

Homeowners Insurance

Condo Insurance

ATV Insurance

Watercraft/Boat Insurance

Collector Car Insurance

Flood Insurance

Motorcycle Insurance

RV - Motorhome Insurance

Renter's Insurance

Golf Cart Insurance

Umbrella Insurance

Wedding Insurance

Mobile/Manufactured Home Insurance:

Property Address:(Required)

Same as Mailing Address

Street Address City State ZIP Code

Have you Lived at the Current Address for 3 years or more?:(Required)

Prior Address:(Required)

Street Address City State ZIP Code

Years at Current Address:(Required)

Square Feet in Home:(Required)

Home Usage:(Required)

Year Originally Built:(Required)

Do you know the Manufacturer of your Home?:(Required)

Manufacturer of Mobile/Manufactured Home:(Required)

Is your Mobile/Manufactured Home in a Community?:(Required)

Name of Park or Community:(Required)

Floor Type:(Required)

Tile

Carpet

Laminate

Hardwood

Vinyl

Marble

Terrazzo

Home Exterior Construction Material:(Required)

Home Framing Construction Material:(Required)

How many Stories is your Home:(Required)

Type of Foundation Material:(Required)

Water Heater Location:(Required)

Water Heater Type:(Required)

Plumbing Material:(Required)

Heating Type:(Required)

Do you have a Garage?:(Required)

What type of Garage is it?:(Required)

Number of Garage Stalls:(Required)

Do you know the Size of your Mobile/Manufactured Home:(Required)

Length of Mobile/Manufactured Home (in Feet):(Required)

Width of Mobile/Manufactured Home (in Feet):(Required)

Shape of Roof on Home:(Required)

Type of Roof Materials:(Required)

Was the Roof Replaced?:(Required)

Year of Last roof Replacement:(Required)

Do you have a Pool?:(Required)

Pool Type:(Required)

Is it Screened or Fenced in?:(Required)

Is There a Diving Board or Slide at the Pool?:(Required)

Diving Board

Slide

Neither

Mobile/Manufactured Home Attachments:

Do you have a Carport:(Required)

Carport Length (in Feet):(Required)

Carport Width (in Feet):(Required)

Do you have an Enclosed Garage:(Required)

Enclosed Garage Length (in Feet):(Required)

Enclosed Garage Width (in Feet):(Required)

Do you have a Screen room:(Required)

Screen Room Length (in Feet):(Required)

Screen Room Width (in Feet):(Required)

Do you have a Weather Tight room:(Required)

Weather Tight Room Length (in Feet):(Required)

Weather Tight Room Width (in Feet):(Required)

Do you have a Shed:(Required)

Shed Length:(Required)

Shed Width:(Required)

Auto Insurance:

Garaging Address:(Required)

Same as Mailing Address

Street Address City State ZIP Code

Is the Residence a(n):(Required)

Residence Type:(Required)

Years at the Current Address:(Required)

Years Continuously Insured:(Required)

Desired Policy Term:(Required)

Preferred Policy Payment:(Required)

What is your Desired Limit of Bodily Injury?:(Required)

What is your Desired Limit of Property Damage?:(Required)

When is Coverage Needed?:

MM slash DD slash YYYY

Do you have an Auto Policy now without a 30 day Lapse in Coverage:(Required)

Current Insurance Company(Required)

Policy Expiration Date:(Required)

MM slash DD slash YYYY

Insurance Policy Premium:(Required)

Years with the Current Carrier:(Required)

What are your Current Liability Limits?:(Required)

Drivers:

How many Permitted drivers will be Operating the Vehicle (Including Yourself):(Required)

Driver 1:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Gender:(Required)

Education:(Required)

Occupation:(Required)

Marital Status:(Required)

Relationship to Applicant:(Required)

Age First Licensed:(Required)

Any Claims or Violations:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Driver 2:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Gender:(Required)

Education:(Required)

Occupation:(Required)

Marital Status:(Required)

Relationship to Applicant:(Required)

Age First Licensed:(Required)

Any Claims or Violations:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Driver 3:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Gender:(Required)

Education:(Required)

Occupation:(Required)

Marital Status:(Required)

Relationship to Applicant:(Required)

Age First Licensed:(Required)

Any Claims or Violations:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Driver 4:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Gender:(Required)

Education:(Required)

Occupation:(Required)

Marital Status:(Required)

Relationship to Applicant:(Required)

Age First Licensed:(Required)

Any Claims or Violations:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Driver 5:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Gender:(Required)

Education:(Required)

Occupation:(Required)

Marital Status:(Required)

Relationship to Applicant:(Required)

Age First Licensed:(Required)

Any Claims or Violations:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Driver 6:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Gender:(Required)

Education:(Required)

Occupation:(Required)

Marital Status:(Required)

Relationship to Applicant:(Required)

Age First Licensed:(Required)

Any Claims or Violations:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Vehicles:

How many Vehicles Should be Added to your Auto Policy:(Required)

Vehicle 1:

Year:(Required)

Make:(Required)

Model:(Required)

VIN:(Required)

Purchase Date:(Required)

MM slash DD slash YYYY

Vehicle Usage:(Required)

Approximate Miles Driven Annually:(Required)

Who will be Operating This Vehicle:(Required)

Approximate Miles to School/Work One Way:(Required)

Desired Comprehensive Deductible:(Required)

Desired Collision Deductible:(Required)

Towing & Labor Coverage:(Required)

Rental Expense Needed:(Required)

Vehicle 2:

Year:(Required)

Make:(Required)

Model:(Required)

VIN:(Required)

Purchase Date:(Required)

MM slash DD slash YYYY

Vehicle Usage:(Required)

Approximate Miles Driven Annually:(Required)

Who will be Operating This Vehicle:(Required)

Approximate Miles to School/Work One Way:(Required)

Desired Comprehensive Deductible:(Required)

Desired Collision Deductible:(Required)

Towing & Labor Coverage:(Required)

Rental Expense Needed:(Required)

Vehicle 3:

Year:(Required)

Make:(Required)

Model:(Required)

VIN:(Required)

Purchase Date:(Required)

MM slash DD slash YYYY

Vehicle Usage:(Required)

Approximate Miles Driven Annually:(Required)

Who will be Operating This Vehicle:(Required)

Approximate Miles to School/Work One Way:(Required)

Desired Comprehensive Deductible:(Required)

Desired Collision Deductible:(Required)

Towing & Labor Coverage:(Required)

Rental Expense Needed:(Required)

Vehicle 4:

Year:(Required)

Make:(Required)

Model:(Required)

VIN:(Required)

Purchase Date:(Required)

MM slash DD slash YYYY

Vehicle Usage:(Required)

Approximate Miles Driven Annually:(Required)

Who will be Operating This Vehicle:(Required)

Approximate Miles to School/Work One Way:(Required)

Desired Comprehensive Deductible:(Required)

Desired Collision Deductible:(Required)

Towing & Labor Coverage:(Required)

Rental Expense Needed:(Required)

Vehicle 5:

Year:(Required)

Make:(Required)

Model:(Required)

VIN:(Required)

Purchase Date:(Required)

MM slash DD slash YYYY

Vehicle Usage:(Required)

Approximate Miles Driven Annually:(Required)

Who will be Operating This Vehicle:(Required)

Approximate Miles to School/Work One Way:(Required)

Desired Comprehensive Deductible:(Required)

Desired Collision Deductible:(Required)

Towing & Labor Coverage:(Required)

Rental Expense Needed:(Required)

Vehicle 6:

Year:(Required)

Make:(Required)

Model:(Required)

VIN:(Required)

Purchase Date:(Required)

MM slash DD slash YYYY

Vehicle Usage:(Required)

Approximate Miles Driven Annually:(Required)

Who will be Operating This Vehicle:(Required)

Approximate Miles to School/Work One Way:(Required)

Desired Comprehensive Deductible:(Required)

Desired Collision Deductible:(Required)

Towing & Labor Coverage:(Required)

Rental Expense Needed:(Required)

Homeowners Insurance:

Property Address:(Required)

Same as Mailing Address

Street Address City State ZIP Code

Have you Lived at the Current Address for 3 years or more?:(Required)

Prior Address:(Required)

Street Address City State ZIP Code

Date Coverage is Needed:(Required)

MM slash DD slash YYYY

Is this a new Purchase?:(Required)

Current Home Carrier:(Required)

Current Policy Expiration Date:(Required)

MM slash DD slash YYYY

Current Annual Premium:(Required)

Do the Sellers Rent:(Required)

Purchase Date:(Required)

MM slash DD slash YYYY

Years at Current Address:(Required)

Square Feet in Home:(Required)

Number of Bedrooms:(Required)

Number of Full Bathrooms:(Required)

Number of Half Bathrooms:(Required)

Home Usage:(Required)

Roof Material:(Required)

Shape of Roof on Home:(Required)

Was the Roof Replaced?:(Required)

Year of last Roof Replacement:(Required)

Floor Type:(Required)

Tile

Carpet

Laminate

Hardwood

Vinyl

Marble

Terrazzo

Structure Type:(Required)

Year Built:(Required)

Home Exterior Construction Material:(Required)

Type of Foundation Material:(Required)

Home Framing Construction Material:(Required)

How many Stories is your Home:(Required)

Water Heater Type:(Required)

Water Heater Location:(Required)

Plumbing Material:(Required)

Cast Iron

Copper

PEX

Polybutylene

PVC

Other

Heating Type:(Required)

Do you have a Garage?:(Required)

What type of Garage is it?:(Required)

Number of Garage Stalls:(Required)

Do you have a Carport?:(Required)

Type of Carport:(Required)

Do you have a Pool?:(Required)

Pool Type:(Required)

Is it Screened or Fenced in?:(Required)

Is There a Diving Board or Slide at the Pool?:(Required)

Diving Board

Slide

Neither

Have you had any Claims at this or any Address in the past 5 years:(Required)

Date of Claim:(Required)

MM slash DD slash YYYY

Value of Claim:(Required)

Detail of Claim:(Required)

Condo Insurance:

Condo Association Name:(Required)

Owned or Rented?:(Required)

Property Address:(Required)

Same as Mailing Address

Street Address City State ZIP Code

Condo Usage:(Required)

Number of Units in the Building:(Required)

Number of Floors in Building:(Required)

Is there a Sprinkler System in the Building:(Required)

Do you have a copy of the Wind Mitigation Inspection Report (If so, Please use the File upload at the Bottom of the page to Send it our way):(Required)

Have you had any Claims at this or any Address in the past 5 years:(Required)

Date of Claim:(Required)

MM slash DD slash YYYY

Value of Claim:(Required)

Detail of Claim:(Required)

All-Terrain Vehicle Insurance:

Garaging Address:(Required)

Same as Mailing Address

Street Address City State ZIP Code

Do you have an ATV Policy now without a 30 day Lapse in Coverage:(Required)

Name of Other Provider:(Required)

Expiration Date:(Required)

MM slash DD slash YYYY

Yearly Estimated Premium:(Required)

Riders:

How many Permitted drivers will be Operating the Vehicle (Including Yourself):(Required)

Rider 1:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Has this Rider Taken a Safety Course:(Required)

Date of Rider Safety Course:(Required)

MM slash DD slash YYYY

Number of Years Riding:(Required)

Rider 2:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Has this Rider Taken a Safety Course:(Required)

Date of Rider Safety Course:(Required)

MM slash DD slash YYYY

Number of Years Riding:(Required)

Rider 3:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Has this Rider Taken a Safety Course:(Required)

Date of Rider Safety Course:(Required)

MM slash DD slash YYYY

Number of Years Riding:(Required)

All-Terrain Vehicles:

How many Vehicles Should be Added to your ATV Policy:(Required)

All-Terrain Vehicle 1:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Usage:(Required)

Engine Size (cc):(Required)

All-Terrain Vehicle 2:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Usage:(Required)

Engine Size (cc):(Required)

All-Terrain Vehicle 3:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Usage:(Required)

Engine Size (cc):(Required)

All-Terrain Vehicle 4:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Usage:(Required)

Engine Size (cc):(Required)

Watercraft/Boat Insurance:

Where is the Watercraft Stored:(Required)

How is the Watercraft Stored:(Required)

Number of Months out of a year Stored there:(Required)

Are you the Original Owner:(Required)

Was the Title Transferred?:(Required)

Is the Watercraft Registered?:(Required)

How many Persons will be Operating the Watercraft?:(Required)

Driver 1:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Gender:(Required)

Any Claims, Accidents, or Violations in the past 5 years:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Driver 2:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Gender:(Required)

Any Claims, Accidents, or Violations in the past 5 years:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Driver 3:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Gender:(Required)

Any Claims, Accidents, or Violations in the past 5 years:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Driver 4:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Gender:(Required)

Any Claims, Accidents, or Violations in the past 5 years:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

How many Watercrafts do you own?:(Required)

Watercraft 1:

Year:(Required)

Make:(Required)

Model:(Required)

Hull Identification Number:(Required)

Original Purchase Price:(Required)

Approximate Value:(Required)

Hull Type (Boat Type):(Required)

Number of Engines:(Required)

Year of Engine 1:(Required)

Year of Engine 2:(Required)

Year of Engine 3:(Required)

Year of Engine 4:(Required)

Max Speed of Boat/Watercraft:(Required)

Total Horsepower of Engine(s):(Required)

Propulsion Type:(Required)

Watercraft Hull Material :(Required)

Hull Length (in Feet):(Required)

Do you use a Trailer to Transport the Watercraft:(Required)

Trailer Year:(Required)

Trailer Make:(Required)

Would you like Trailer Coverage:(Required)

Would you like Ice and Freeze Coverage:(Required)

Do you Require a Deductible for any Special Electronics on the Watercraft:(Required)

Would you Like to Purchase Commercial Towing and Assistance Coverage?:(Required)

Is Named Storm Exclusion Needed:(Required)

Do you Require Bahamas Coverage:(Required)

Watercraft 2:

Year:(Required)

Make:(Required)

Model:(Required)

Hull Identification Number:(Required)

Original Purchase Price:(Required)

Approximate Value:(Required)

Hull Type (Boat Type):(Required)

Number of Engines:(Required)

Year of Engine 1:(Required)

Year of Engine 2:(Required)

Year of Engine 3:(Required)

Year of Engine 4:(Required)

Max Speed of Boat/Watercraft:(Required)

Total Horsepower of Engine(s):(Required)

Propulsion Type:(Required)

Watercraft Hull Material :(Required)

Hull Length (in Feet):(Required)

Do you use a Trailer to Transport the Watercraft:(Required)

Trailer Year:(Required)

Trailer Make:(Required)

Would you like Trailer Coverage:(Required)

Would you like Ice and Freeze Coverage:(Required)

Do you Require a Deductible for any Special Electronics on the Watercraft:(Required)

Would you Like to Purchase Commercial Towing and Assistance Coverage?:(Required)

Is Named Storm Exclusion Needed:(Required)

Do you Require Bahamas Coverage:(Required)

Watercraft 3:

Year:(Required)

Make:(Required)

Model:(Required)

Hull Identification Number:(Required)

Original Purchase Price:(Required)

Approximate Value:(Required)

Hull Type (Boat Type):(Required)

Number of Engines:(Required)

Year of Engine 1:(Required)

Year of Engine 2:(Required)

Year of Engine 3:(Required)

Year of Engine 4:(Required)

Max Speed of Boat/Watercraft:(Required)

Total Horsepower of Engine(s):(Required)

Propulsion Type:(Required)

Watercraft Hull Material :(Required)

Hull Length (in Feet):(Required)

Do you use a Trailer to Transport the Watercraft:(Required)

Trailer Year:(Required)

Trailer Make:(Required)

Would you like Trailer Coverage:(Required)

Would you like Ice and Freeze Coverage:(Required)

Do you Require a Deductible for any Special Electronics on the Watercraft:(Required)

Would you Like to Purchase Commercial Towing and Assistance Coverage?:(Required)

Is Named Storm Exclusion Needed:(Required)

Do you Require Bahamas Coverage:(Required)

Collector Car Insurance:

Garaging Address:(Required)

Same as Mailing Address

Street Address City State ZIP Code

How many Vehicles Should be Added to your Collector Car Insurance Policy:(Required)

Vehicle 1:

Year:(Required)

Make:(Required)

Model:(Required)

VIN:(Required)

Are there any Modifications to the Vehicle:(Required)

Is the Car Kept in a Garage, Barn, or Carport?:(Required)

What Modifications:(Required)

Turbo/Nitrous

Custom Paint

Custom Rims

Custom Frame

Is the Vehicle used for Racing, Timed Events, AutoCross, or other High Performance Sports:(Required)

Vehicle Value (If you're unsure about this, you can just put the price you paid):(Required)

Is the Vehicle used as a Daily Driver for more than a month out of the year:(Required)

Vehicle 2:

Year:(Required)

Make:(Required)

Model:(Required)

VIN:(Required)

Are there any Modifications to the Vehicle:(Required)

Is the Car Garage Kept, in a Barn, or Under a Carport:(Required)

What Modifications:(Required)

Turbo/Nitrous

Custom Paint

Custom Rims

Custom Frame

Is the Vehicle used for Racing, Timed Events, AutoCross, or other High Performance Sports:(Required)

Vehicle Value (If you're unsure about this, you can just put the price you paid):(Required)

Is the Vehicle used as a Daily Driver for more than a month out of the year:(Required)

Vehicle 3:

Year:(Required)

Make:(Required)

Model:(Required)

VIN:(Required)

Are there any Modifications to the Vehicle:(Required)

Is the Car Garage Kept, in a Barn, or Under a Carport:(Required)

What Modifications:(Required)

Turbo/Nitrous

Custom Paint

Custom Rims

Custom Frame

Is the Vehicle used for Racing, Timed Events, AutoCross, or other High Performance Sports:(Required)

Vehicle Value (If you're unsure about this, you can just put the price you paid):(Required)

Is the Vehicle used as a Daily Driver for more than a month out of the year:(Required)

Vehicle 4:

Year:(Required)

Make:(Required)

Model:(Required)

VIN:(Required)

Are there any Modifications to the Vehicle:(Required)

Is the Car Garage Kept, in a Barn, or Under a Carport:(Required)

What Modifications:(Required)

Turbo/Nitrous

Custom Paint

Custom Rims

Custom Frame

Is the Vehicle used for Racing, Timed Events, AutoCross, or other High Performance Sports:(Required)

Vehicle Value (If you're unsure about this, you can just put the price you paid):(Required)

Is the Vehicle used as a Daily Driver for more than one month out of the year:(Required)

Flood Insurance:

Property Address:(Required)

Same as Mailing Address

Street Address City State ZIP Code

Building Type:(Required)

Please Describe Other:(Required)

Value of Building:(Required)

Value of Contents in Home:(Required)

How is the Property Occupied:(Required)

How many days out of the year does the Owner Occupy the Property:(Required)

How many days out of the year does the Tenant Occupy the Property:(Required)

Do you have a Copy of the Elevation Certificate (If so, Please use the File Upload at the Bottom of the page to get it to us):(Required)

Is this a new Purchase:(Required)

What year was the Property Purchased:(Required)

Do you have a Flood Policy now without a 30 day Lapse in Coverage:(Required)

Prior Provider Name:(Required)

Expiration Date:(Required)

MM slash DD slash YYYY

Yearly Premium:(Required)

Has there been any Claims or Losses in the past 6 Months at this or any Other Address:(Required)

Value of Loss:(Required)

Loss Date:(Required)

MM slash DD slash YYYY

Detail of Loss:(Required)

Motorcycle Insurance:

Garaging Address:(Required)

Same as Mailing Address

Street Address City State ZIP Code

Do you have a Motorcycle Policy now without a 30 day Lapse in Coverage:(Required)

Name of Provider:(Required)

Expiration Date:(Required)

MM slash DD slash YYYY

Yearly Premium:(Required)

Riders:

How many Permitted drivers will be Operating the Vehicle (Including Yourself):(Required)

Rider 1:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Has this Rider Taken a Safety Course:(Required)

Date of Rider Safety Course:(Required)

MM slash DD slash YYYY

Number of Years Riding:(Required)

Rider 2:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Has this Rider Taken a Safety Course:(Required)

Date of Rider Safety Course:(Required)

MM slash DD slash YYYY

Number of Years Riding:(Required)

Rider 3:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Details of Incident:(Required)

Date of Incident:(Required)

MM slash DD slash YYYY

Has this Rider Taken a Safety Course:(Required)

Date of Rider Safety Course:(Required)

MM slash DD slash YYYY

Number of Years Riding:(Required)

Motorcycles:

How many Vehicles Should be Added to your Motorcycle Policy:(Required)

Motorcycle 1:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Usage:(Required)

Engine Size (cc):(Required)

Motorcycle 2:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Usage:(Required)

Engine Size (cc):(Required)

Motorcycle 3:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Usage:(Required)

Engine Size (cc):(Required)

RV/Motorhome Insurance:

Storage Address:(Required)

Same as Mailing Address

Street Address City State ZIP Code