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Auto/Home Quote Information Request
Below is the information needed for Kelly to get started your quote.
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* Indicates required question
Email
*
Your email
First and Last Name
*
Your answer
Address
*
Your answer
City, State, and Zip
*
Your answer
Phone Number
*
Your answer
Type of Phone
*
Cell
Home
Please provide the name of the person that referred you.
*
Your answer
Military Status/Government Employee
Retired Military
Active Military
Government Employee
Clear selection
What is your occupation?
*
Your answer
Who is your current insurer for home and/or auto? What is the renewal date and premium amount?
Your answer
Home Information
Do the best you can to answer these questions regarding your current home.
What year was your home built?
Your answer
What is your home's construction style?
Brick or frame, if both please note the majority. For example, 80% brick/20% frame.
Your answer
# of stories
Your answer
Square footage
Your answer
# of bathrooms
Your answer
If you have a pool, please list the type (above ground or inground).
Your answer
Basement type (Finished/Unfinished/Crawl/Slab)
Your answer
Type of garage (attached/detached) and # of car spaces
Your answer
Year the property was purchased
Your answer
Please list any claims from the last 5 years.
Your answer
Name and date of birth for each person listed on title.
*
Your answer
Driver's license number for each person listed on title.
*
While the question seems odd for homeowner's insurance, some carriers now review accident history when determining rate for the homeowner's insurance.
Your answer
Please give original age of the roof or year of last replacement.
*
Your answer
Please list your current dwelling coverage, liability, deductible, and medical payment limits.
Your answer
Auto Information
Do the best you can to answer these questions regarding your current auto policy.
List the name of each driver with their date of birth and driver's license number.
*
Your answer
Any accidents or tickets in the past 5 years? List the date of incident and if at fault.
Your answer
List each vehicle (Make/Model, Year, and VIN #)
Your answer
What are your current liability limits?
Your answer
What is your current property damage limit?
Your answer
What are your current comprehensive and collision limits?
Your answer
Do you have towing, rental or glass coverage? If so, what are the limits?
Your answer
If you have any special coverages or limits per vehicle list them here.
Your answer
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