Get a Quote Now! - Lee County Insurance

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Step 1 of 32

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

Business Information:

Name of Business:(Required)

Name of Owner:(Required)

First Last

Phone Number:(Required)

Email Address:(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:

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)

Value of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Details of the Violation:(Required)

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)

Value of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Details of the Violation:(Required)

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)

Value of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Details of the Violation:(Required)

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)

Value of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Details of the Violation:(Required)

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)

Value of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Details of the Violation:(Required)

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)

Value of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Details of the Violation:(Required)

Vehicles:

How many Vehicles Should be Added to your Business Auto 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)

Vehicle 5:

Year:(Required)

Make:(Required)

Model(Required)

VIN:(Required)

Vehicle Usage:(Required)

Vehicle 6:

Year:(Required)

Make:(Required)

Model(Required)

VIN:(Required)

Vehicle Usage:(Required)

Business Property Insurance:

Services Provided:(Required)

Value of Property:(Required)

Desired Total Liability Amount:(Required)

Expected Sales for the Year:(Required)

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

Value of Loss:(Required)

Date of Loss:(Required)

MM slash DD slash YYYY

Detail of Loss:(Required)

Commercial Trucking Insurance:

Business Structure:(Required)

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)

Is there any Permanently Attached Equipment or Hardware:(Required)

Total Approximate Value of Attached Equipment or Hardware:(Required)

Do you have a USDOT #:(Required)

USDOT Number:(Required)

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

States Traveled to:(Required)

Select One

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

District 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 the Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Value of Violation:(Required)

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)

Value of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Details of the Violation:(Required)

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)

Value of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Details of the Violation:(Required)

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)

Value of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Details of the Violation:(Required)

Cargo and Trailer Coverage:

Do you want Cargo Coverage:(Required)

What Limit:(Required)

What Deductible:(Required)

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

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 under 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 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 Commercial Firm:(Required)

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

Are there Portable Fire Extinguishers:(Required)

Number is 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 any Delivery Service:(Required)

How is the Delivery Service Carried Out:(Required)

If Other, Please Explain Here:(Required)

Delivery Service Done by:(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 Violation 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 Violation Details:(Required)

Please Indicate any Entertainment Provided:(Required)

Live Music

Dance Floor

Karaoke

Arcade Games

Amusement Devices

Other

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

Cell Phone Number:(Required)

Email Address:(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

Renters Insurance

Golf Cart Insurance

Umbrella Insurance

Wedding Insurance

Mobile/Manufactured Home Insurance:

Is the Property Address the Same as the Mailing Address?:(Required)

Property Address:(Required)

Street Address City State ZIP Code

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)

Home Usage:(Required)

Year Originally Built:(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)

Type of Roof Materials:(Required)

Was the Roof Replaced?:(Required)

Year of Last roof Replacement:(Required)

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:

Is the Garaging Address the Same as the Mailing Address?:(Required)

Address(Required)

Street Address City State ZIP Code

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

Do you have an 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)

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)

Any Claims or Violations:(Required)

Value of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Details of the Violation:(Required)

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)

Value of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Details of the Violation:(Required)

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)

Value of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Details of the Violation:(Required)

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)

Value of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Details of the Violation:(Required)

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)

Value of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Details of the Violation:(Required)

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)

Value of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Details of the Violation:(Required)

Vehicles:

How many Vehicles Should be Added to your Auto 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)

Vehicle 5:

Year:(Required)

Make:(Required)

Model:(Required)

VIN:(Required)

Vehicle Usage:(Required)

Vehicle 6:

Year:(Required)

Make:(Required)

Model:(Required)

VIN:(Required)

Vehicle Usage:(Required)

Homeowners Insurance:

Home Usage:(Required)

Roof Material:(Required)

Shape of Roof on Home if Known:(Required)

Has the Roof been Replaced?:(Required)

Year of last Roof Replacement:(Required)

Is the Property Address the Same as the Mailing Address?:(Required)

Property Address:(Required)

Street Address City State ZIP Code

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

Date of Loss:(Required)

MM slash DD slash YYYY

Value of Loss:(Required)

Detail of Loss:(Required)

Condo Insurance:

Condo Association Name:(Required)

Is the Property Address the Same as the Mailing Address?:(Required)

Property Address:(Required)

Street Address City State ZIP Code

Condo Usage:(Required)

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

Date of Loss:(Required)

MM slash DD slash YYYY

Value of Loss:(Required)

Detail of Loss:(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)

All-Terrain Vehicle Insurance:

Is the Garaging Address the Same as the Mailing Address?:(Required)

Garaging Address:(Required)

Street Address City State ZIP Code

Engine Size (cc):(Required)

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)

Value of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Details of the Violation:(Required)

Has this Rider Taken a Safety Course:(Required)

Date of Rider Safety Course:(Required)

MM slash DD slash YYYY

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)

Value of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Details of the Violation:(Required)

Has this Rider Taken a Safety Course:(Required)

Date of Rider Safety Course:(Required)

MM slash DD slash YYYY

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)

Value of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Details of the Violation:(Required)

Has this Rider Taken a Safety Course:(Required)

Date of Rider Safety Course:(Required)

MM slash DD slash YYYY

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)

All-Terrain Vehicle 2:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Usage:(Required)

All-Terrain Vehicle 3:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Usage:(Required)

All-Terrain Vehicle 4:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Usage:(Required)

Watercraft/Boat Insurance:

Where is the Boat Stored:(Required)

How is the Boat Stored:(Required)

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

Are you the Original Owner:(Required)

Original Purchase Price:(Required)

Approximate Value:(Required)

Hull Identification Number:(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)

Hull Material Type:(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)

Collector Car Insurance:

Is the Garaging Address the Same as the Mailing Address?:(Required)

Garaging Address:(Required)

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)

Vehicle Identification Number:(Required)

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

Are there any Modifications to the Vehicle:(Required)

What Modifications:(Required)

Increased Horsepower

Custom Paint

Custom Rims

Custom Frame

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

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

Vehicle Identification Number:(Required)

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

Are there any Modifications to the Vehicle:(Required)

What Modifications:(Required)

Increased Horsepower

Custom Paint

Custom Rims

Custom Frame

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

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

Vehicle Identification Number:(Required)

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

Are there any Modifications to the Vehicle:(Required)

What Modifications:(Required)

Increased Horsepower

Custom Paint

Custom Rims

Custom Frame

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

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

Vehicle Identification Number:(Required)

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

Are there any Modifications to the Vehicle:(Required)

What Modifications:(Required)

Increased Horsepower

Custom Paint

Custom Rims

Custom Frame

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

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

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

Flood Insurance:

Is the Property Address the Same as the Mailing Address?:(Required)

Property Address:(Required)

Street Address City State ZIP Code

Building Type:(Required)

Value of Building:(Required)

Value of Contents:(Required)

If Other, Please Describe here:(Required)

How is the Property Occupied:(Required)

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

Do you have a Copy of the 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:

Is the Garaging Address the Same as the Mailing Address?:(Required)

Garaging Address:(Required)

Street Address City State ZIP Code

Engine Size (cc):(Required)

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)

Detail of Violation:(Required)

Value of Violation:(Required)

Date of Violation:(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

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)

Detail of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Value of Violation:(Required)

Has this Rider Taken a Safety Course:(Required)

Date of Rider Safety Course:(Required)

MM slash DD slash YYYY

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)

Detail of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Value of Violation:(Required)

Has this Rider Taken a Safety Course:(Required)

Date of Rider Safety Course:(Required)

MM slash DD slash YYYY

Motorcycles:

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

Motorcycle 1:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Usage:(Required)

Motorcycle 2:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Usage:(Required)

Motorcycle 3:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Usage:(Required)

RV/Motorhome Insurance:

Year of Motorhome:(Required)

Make of Motorhome:(Required)

Approximate Value of Motorhome:(Required)

Vehicle Identification Number:(Required)

Anti-Theft:(Required)

Length of Motorhome (in Feet):(Required)

Motorhome Permanent or Movable:(Required)

About how many days out of the year do you stay in the RV:(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 Violations or Claims:(Required)

Cost of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Detail of Violation(Required)

Driver 2:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Any Violations or Claims:(Required)

Cost of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Detail of Violation(Required)

Driver 3:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Any Violations or Claims:(Required)

Cost of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Detail of Violation(Required)

Driver 4:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Any Violations or Claims:(Required)

Cost of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Detail of Violation(Required)

Driver 5:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Any Violations or Claims:(Required)

Cost of Violation:(Required)

Date of Violation:(Required)

MM slash DD slash YYYY

Detail of Violation(Required)

Renters Insurance:

Is the Property Address the Same as the Mailing Address?:(Required)

Property Address:(Required)

Street Address City State ZIP Code

Type of Residence/Dwelling:(Required)

Value of all Personal Property:(Required)

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

Name Other Coverage Provider:(Required)

Expiration Date of Coverage:(Required)

MM slash DD slash YYYY

Estimated Yearly Premium:(Required)

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

Value of Loss:(Required)

Date of Loss:(Required)

MM slash DD slash YYYY

Detail of Loss:(Required)

Golf Cart Insurance:

Cart Type:(Required)

Make:(Required)

Seat Belt:(Required)

Max Speed:(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 Accidents, Tickets or Claims:(Required)

Total Cost of Violation:(Required)

When did the Violation Occur:(Required)

MM slash DD slash YYYY

What Caused the Violation:(Required)

Driver 2:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Any Accidents, Tickets or Claims:(Required)

Total Cost of Violation:(Required)

When did the Violation Occur:(Required)

MM slash DD slash YYYY

What Caused the Violation:(Required)

Driver 3:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Any Accidents, Tickets or Claims:(Required)

Total Cost of Violation:(Required)

When did the Violation Occur:(Required)

MM slash DD slash YYYY

What Caused the Violation:(Required)

Driver 4:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Any Accidents, Tickets or Claims:(Required)

Total Cost of Violation:(Required)

When did the Violation Occur:(Required)

MM slash DD slash YYYY

What Caused the Violation:(Required)

Driver 5:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Any Accidents, Tickets or Claims:(Required)

Total Cost of Violation:(Required)

When did the Violation Occur:(Required)

MM slash DD slash YYYY

What Caused the Violation:(Required)

Golf Cart Information:

Is the Cart kept in the State of Residence for more than 6 months out of the year:(Required)

Is the Cart ever used by Short Term Renters on the Property:(Required)

Original Purchase Price:(Required)

Actual Cash Value:(Required)

Is there any Additional Optional Equipment:(Required)

Estimated Total Approximate Value of Optional Equipment:(Required)

Umbrella Insurance:

How many Motorized Vehicles Licensed for road use are Owned, Leased, Rented, or Regularly Operated by you or any Member of your Household (Do not Include Antique Vehicles or Collector Cars here):(Required)

How many Residential Properties are owned or rented by you or any Member of your Household (1-4 Family Units is 1 Property; Do not Include Properties Covered by a Commercial General Liability Policy):(Required)

How many Watercraft, OTHER than Canoes, Jet Skis, Waverunners, or other Personal Watercraft are owned or Regularly Operated by you or any Member of your Household:(Required)

How many Jet Skis, Waverunners, or Personal Watercraft are owned or Regularly Operated by you or any Member of your Household:(Required)

How many Drivers will be Operating Vehicles:(Required)

How many Drivers are under the age of 22 (Include Driver's with a Learner's Permit or Valid Driver's License):(Required)

How many Drivers are the age of 70 or over (Include Drivers with a Learner's Permit or Valid Driver's License):(Required)

How many total moving Violations have all drivers had Within the last 3 years (Include DWI/DUI incidents within the last 5 years):(Required)

Has any of the Drivers ages 21 and under or 80 and over had more than one Driving Incident within the past 3 years:(Required)

How many Antique, Classic, or Collectible Vehicles are Owned (Titled or Registered to) by you or any Member of your Household:(Required)

How many Residential Properties are owned or rented by you or any member of your Household are Located outside Canada, Puerto Rico, or the U.S. (Including U.S. Territories):(Required)

How many Acres of land do you or any Member of your Household own or lease (Including Partial Ownership; Do not Include land Covered by a General Liability Policy):(Required)

How many Driving Incidents have all the Drivers 21 and under and/or 80 and over had within the last 3 years:(Required)

Have you or any Member of your Household been Indicted, Charged, or Convicted of a felony within the last 5 years:(Required)

What type of Liability Limits are Desired for Your Umbrella Policy:(Required)

How many at-fault Accidents have all drivers had in the last 3 years:(Required)

Have you or any other driver had an Arrest, Citation, or Conviction for Reckless Driving, Careless Driving (with 4 points), Negligent Driving, and/or had a Driver's License Suspended, Revoked, or Refused in the last 5 years (for Reasons other than Driving under the Influence of Alcohol or Drugs):(Required)

How many arrests, citations, or license suspensions for driving under the Influence of Alcohol/Drugs and/or driving while Intoxicated and/or other Alcohol/Drug related Incidents have all Drivers had in the last 5 years:(Required)

Do you or any Member of your Household have an Occupation of a Professional Entertainer, Athlete, or Media Personality:(Required)

Has any one Driver had more than 3 moving Violations within the last 3 years (Include DWI/DUI Incidents within the last 5 years):(Required)

How many Licensed Drivers will be Operating any Vehicles:(Required)

Driver 1:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Relationship to the Applicant:(Required)

Number of Violations 3 years (Including DWI/DUI 5 years/3 years in MT):(Required)

Number of At-Fault Accidents (3 years):(Required)

Driver 2:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Relationship to the Applicant:(Required)

Number of Violations 3 years (Including DWI/DUI 5 years/3 years in MT):(Required)

Number of At-Fault Accidents (3 years):(Required)

Driver 3:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Relationship to the Applicant:(Required)

Number of Violations 3 years (Including DWI/DUI 5 years/3 years in MT):(Required)

Number of At-Fault Accidents (3 years):(Required)

Driver 4:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Relationship to the Applicant:(Required)

Number of Violations 3 years (Including DWI/DUI 5 years/3 years in MT):(Required)

Number of At-Fault Accidents (3 years):(Required)

Driver 5:

Name:(Required)

First Last

Date of Birth:(Required)

MM slash DD slash YYYY

Drivers License Number:(Required)

Drivers License State:(Required)

Relationship to the Applicant:(Required)

Number of Violations 3 years (Including DWI/DUI 5 years/3 years in MT):(Required)

Wedding Insurance:

How many Days of Coverage do you Need:(Required)

Event Start Date:(Required)

MM slash DD slash YYYY

Event End Date:(Required)

MM slash DD slash YYYY

Number of Guests Attending:(Required)

Are there any Amusement Devices, Rides or Animals, or other Entertainment Options:(Required)

Have You or Anyone Attending the Event had More than 1 Event Claim Over $10,000 in the Past 5 Years(Required)

Will You or Anyone at the Event be Operating a Golf Cart, ATV, or a UTV:(Required)

Alcohol Coverage:(Required)

Coverage Limit:(Required)

Medical Payments:(Required)

Deductible:(Required)

Would you also like Wedding Cancellation Coverage (If you would, your Scheduled Event Date must be more than 7 Days Away):(Required)

Location Name:(Required)

Street Address of Event:(Required)

City:(Required)

Where is your Event Located:(Required)

Zip Code:(Required)

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