Home Quote Sheet "*" indicates required fields Step 1 of 11 9% Can I start with getting your first and last name please?* First Last How did you hear about us? (Lead Source)*Google/Search EngineFriendFamilySocial MediaOtherDo you mind providing their name so we can match you with their agent?Other:Is there a writing agent you are already working with?- None -Tim HarrellLindsay HarrisDavid AllenBryan BatchelorAre you currently insured?* Yes No When do you need your insurance to start?* MM slash DD slash YYYY (Effective Date) "A few questions about your house..."What's the address of the property you're needing to insure?* Street Address City State / Province / Region ZIP / Postal Code How long have you lived at the address above? More than 2 years Less than 2 years New Purchase Secondary Home or Rental Previous Address* Street Address City State / Province / Region ZIP / Postal Code Current Address* Street Address City State / Province / Region ZIP / Postal Code Closing Date MM slash DD slash YYYY Purchase PriceHome details available online? (Google, Zillow, Trulia, etc) Yes No Type of Home? Single Family Home Mobile Home Townhouse Condo Year BuiltSquare FootageFoundationConstruction TypeNumber of StoriesNumber of Baths/Half BathsGarage? Size?Porches? Size?Mobile Home Style Single Wide Double Wide Skirting Vinyl Brick Block Length & WidthYear & ManufactureDo you know what year the roof was last replaced? What's your best guess?*"This helps us get you the most accurate rate. If you're buying the home, this could be on the sellers disclosure or Zillow listing."**For homes > 10 years old - "Do you what know year these systems where last updated? "HVACElectricalPlumbing Add Remove "Now I need to ask a few questions about you..."What is your Date of Birth?* MM slash DD slash YYYY What is your job title and industry or What kind of work do you do?"Some companies use this a rating factor especially on the auto quote which we'll get to in a minute"What is your Marital Status?* Single Married Domestic Partner Divorced/Separated Widowed What is your spouse's name (or partner's)? First Last 2nd Person/Spouse - Date of Birth MM slash DD slash YYYY 2nd Person/Spouse - Job Title/Industry Coverage QuestionsDo you have any jewelry or firearms that exceed $1500 total?"Most policies cover these items up to $1500 total, but they're subject to your deductible. If you have a collection of jewelry, cameras, musical instruments, fine art, firearms, or anything else of higher value there are coverages available (Scheduled Personal Property - SPP) for an additional cost that would give you extra coverage for personal property with NO deductible." **Please attach photos and appraisals later in form**Do you have any pets? No Yes Type, Number, and Breed(restricted dogs can include: Doberman, Rottweiler, Pit Bull, Chow Chow, German Shepard. Each carrier has a slightly different list.) If someone has one of these dogs, "We may have to exclude animal liability if the dog bites or hurts someone by jumping on them so you'd need to be certain that your animal wouldn't hurt someone and you're not worried about a lawsuit because of your dog." Do you have a trampoline? No Yes Does your trampoline have safety netting? Yes No Do you have a swimming pool? No Yes Pool Type? Above Ground Inground Slide? No Yes Diving Board? No Yes Is it completely enclosed with a fence and locked gate? No Yes Would you like us to look at your auto as well? Yes No This could provide a multi-policy discount, lowering the premium of both policies. Driver InfoDriver's License NumberAdd Spouse/Partner? Yes No What is your spouse's name (or partner's)? First Last Spouse/Partner's Driver's License NumberAdd Additional Driver? Yes No Additional DriverRelationshipDriver's License NumberDate of Birth MM slash DD slash YYYY Add Additional Driver? Yes No Additional DriverRelationshipDriver's License NumberDate of Birth MM slash DD slash YYYY Add Additional Driver? Yes No Additional DriverRelationshipDriver's License NumberDate of Birth MM slash DD slash YYYY Add Additional Driver? Yes No Additional DriverRelationshipDriver's License NumberDate of Birth MM slash DD slash YYYY Coverage Questions **SKIP if uploading current declarations page***Bodily Injury Limits30,000/60,00050,000/100,000100,000/100,000100,000/300,000300,000/300,000250,000/500,000500,000/500,000500,000/1,000,0001,000,000/1,000,0001,000,000/2,000,000Property Damage25,00050,000100,000250,000300,000500,000750,0001,000,000Medical Payments- None -$1,000$2,000$5,000$10,000$25,000$50,000$75,000$100,000Comprehensive/Other than Collision Deductible- None -$1000$500$250$100$0Collision Deductible- None -$1000$500$250$100$0Rental- None -$30/Day - $900/Loss$50/Day - $1500/LossTowing- None -$50$100 "Now tell us about your vehicle(s)..." **SKIP if uploading declarations page**YearMakeModelVINUntitled Liability Only Full Coverage Add Additional Vehicle? Yes No YearMakeModelVINUntitled Liability Only Full Coverage Add Additional Vehicle? Yes No YearMakeModelVINUntitled Liability Only Full Coverage Add Additional Vehicle? Yes No YearMakeModelVINUntitled Liability Only Full Coverage Add Additional Vehicle? Yes No YearMakeModelVINUntitled Liability Only Full Coverage "Just Some Final Things..."Email "What's the best email address for us to send the proposal once we've done our research with our multiple companies?"Spouse/Partner's Email Phone"Do you mind if we text you once we have the quotes completed to let you know to look at your email?"Spouse/Partner's PhonePreferred Way of Contact? Phone Call Email Please Upload Any Significant Documents (i.e. current declarations pages, property photos, etc.) Drop files here or Select files Max. file size: 98 MB. Notes(Anything else we should know?) **OPTIONAL - Customer Service Quesitons**OPTIONAL -What's prompting you to look at your insurance? (SKIP if this is purchasing) (We're looking for pain points with their current policy - are they looking for a lower price, did they experience bad service, poor claims experience?)**OPTIONAL - What did you like or dislike most about your current agent/company?"We want to know what to do or NOT to do to keep you as a customer for life"Untitled
