Auto Quote Sheet "*" indicates required fields Step 1 of 10 10% 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) "Now to ask a few questions about you and the other drivers..."Current Address* Street Address City State / Province / Region ZIP / Postal Code How long have you lived at the address above?* More than 3 years Less than 3 years Previous Address* Street Address City State / Province / Region ZIP / Postal Code Driver's License Number*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 as 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 Spouse - Driver's License Number*Spouse - Date of Birth* MM slash DD slash YYYY Spouse - Job Title/IndustryAdd Additional Driver? Yes No Additional Driver*Relationship*Driver's License Number*Date of Birth* MM slash DD slash YYYY Add Additional Driver? Yes No Additional Driver*Relationship*Driver's License Number*Date of Birth* MM slash DD slash YYYY Add Additional Driver? Yes No Additional Driver*Relationship*Driver's License Number*Date of Birth* MM slash DD slash YYYY Add Additional Driver? Yes No Additional Driver*Relationship*Driver's License Number*Date 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**YearMakeModelVINFull or Liability Liability Only Full Coverage Add Additional Vehicle? Yes No YearMakeModelVINFull or Liability Liability Only Full Coverage Add Additional Vehicle? Yes No YearMakeModelVINFull or Liability Liability Only Full Coverage Add Additional Vehicle? Yes No YearMakeModelVINFull or Liability Liability Only Full Coverage Add Additional Vehicle? Yes No YearMakeModelVINFull or Liability Liability Only Full Coverage Would you like us to look at your home as well? Yes No Possibly at later date This could provide a multi-policy discount, lowering the premium of both policies. Some questions about your home...Type of Home? Single Family Home Mobile Home Townhouse Condo Home details available online? (Google, Zillow, Trulia, etc) Yes No 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 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."Do you have any pets? Yes No 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? Yes No Does your trampoline have safety netting? Yes No Do you have a swimming pool? Yes No Pool Type? Above Ground Inground Slide? Yes No Diving Board? Yes No Is it completely enclosed with a fence and locked gate? Yes No "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?"Phone"Do you mind if we text you once we have the quotes completed to let you know to look at your email?"Preferred Way of Contact Phone Call Email Please Upload Any Significant Documents (i.e. current declarations pages, driver's license, etc.) Drop files here or Select files Max. file size: 98 MB. Notes(Anything else we should know?) **OPTIONAL - Customer Service Questions**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"
