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Auto & Home Combo Form
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Auto & Home Combo Form
Your Information
First Name
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Middle Initial
Last Name
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Date of Birth
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MM slash DD slash YYYY
Drivers License #
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Gender
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Male
Female
Occupation
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Highest Level of Education
Mobile Phone
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Work Phone
Email Address
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Prefer Method Of Contact
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Voice/Phone
Email
Text
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Current Address
Street Address
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City
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State
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Zip
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County
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Have you lived at your Current Address Less Than 3 Years?
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Yes
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Years lived at Current Address?
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Previous Address
Street Address
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City
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State
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Zip
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County
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Secondary / Spouse Information
First Name
Middle Initial
Last Name
Date of Birth
Drivers License Number
Gender
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Male
Female
Occupation
Highest Level of Education
Mobile Phone
Work Phone
Email Address
Physical Address
Mailing Address
Type of Insurance Needed
Select the type of insurance you need below.
*
Select
Auto
Home
Auto and Home
Auto Insurance Section
Driver(s) Info
Driver Name
Date of Birth
Mobile Phone
License Number
State Licensed In
Are you currently active or retired military?
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Yes
No
Are you a member of Triple A?
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Yes
No
Have you taken a Defensive Driving Training class or course?
Select
Yes
No
Telematics
Select
Yes
No
Are you familiar with Telmatic Insurance? If so would you like to participate in Telematic Discount Insurance for a Significant Discount?
Telematics insurance. The central idea is that you can get a discount on your car insurance if you are safer than the typical driver (or if you drive fewer miles than average each year).
Date of Defensive Driving Course
MM slash DD slash YYYY
Triple A
As a member of Triple A, there may be benefits or perks available to you. We can take care of your insurance for other lines such as Renters, Motorcycles, Boats, Motorhomes, Travel Trailers, Commercial lines of insurance as well. Please click Yes if interested.
Select
Yes
No
Give us a few details on what type of property you are interested in getting a quote for and we will call you back to get further info.
Vehicle(s)
Vehicle Year
Vehicle Make
Vehicle Model
Vehicle Vin Number
Vehicle Purchase Date
Vehicle Usage
Select
Work
Pleasure
Miles Driven One Way for Work
Vehicle Garaging Address if different from primary address
Garaging Address ( County )
Have you provided all the drivers residing in your household listed in the Driver(s) Info Section Of the questionnaire above?
Select
Yes
No
Please go back above to Driver(s) Info click the ( + ) sign to add any additional drivers
Current Auto Insurance
Current Insurance Company
Annual Premium
Policy Expiration Date
Coverages Needed
Select
Liability Only
Full Coverage
Limits Needed
Primary Liability
$25 / $50K
$50 / $100K
$100 / $250K
$250 / $500K
CSL $500K
Uninsured/Underinsured Motorist Coverage
$25 / $50K
$50 / $100K
$100 / $250K
$250 / $500K
CSL $500K
PIP
$2,500
$5,000
Medical Payment
$2,500
$5,000
Comprehensive Deductible
$100
$250
$500
$1000
Collision Deductible
$100
$250
$500
$1000
Rental Reimbursement
Total Loss Replacement
GAP / Loan Lease Coverage? (Pays your Creditor in case you total your vehicle within 2 years in some cases)
Select
Yes
No
On what date would you like this coverage to become effective?
MM slash DD slash YYYY
Homeowner Insurance Section
Property Type
Single Family Residence
Condo
Townhome
Duplex
Fourplex
Apartment
Property Owner Occupied
Yes
No
Do you anticipate that this property will ever be unoccupied For more than 30 days once the insurance coverage is effective?
Yes
No
Property Tenant Occupied
Yes
No
If this is a new purchase, what is the closing date?
What is your move-in date?
Property Address (Street, City, State, Zip)
Mailing Address (Street, City, State, Zip) If different than property
Start Date Calculation
Year Home Built
Today's Date
Total Age of Home
Property
Year Home Built
Home Sq Footage
1 Story or 2 Stories
# of Bedrooms
# of Bathrooms
Original Purchase Price
Original Purchase Date
Are you purchasing this home?
Select
Yes
No
If yes, what is closing date?
If yes, what is the closing amount?
Garage
Select
Attached Garage
Detached Garage
Foundation Type
Select
Slab
Pilings
Piers
Crawl Space
Open Crawl Space Enclosed
Basement
Construction
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Brick Veneer
Masonary
Stucco
Hardi Plank
Local Alarm
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Smoke Detectors
Burglar
Central Station Monitored Alarm
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Fire
Burglar
Fire Department Within 5 Miles?
Select
Yes
No
Miles to Fire Department
Responding Fire Dept:
Distance to Hydrant:
Do you have a pool?
Select
Yes
No
Do you have a dog?
Select
Yes
No
Is your home over 40 years old?
Select
Yes
No
Do you have a trampoline?
Select
Yes
No
Is your water heater STANDARD?
Select
Yes
No
Is the Water Heater TANKLESS?
Select
Yes
No
Approximately what is its age?
Select
1 yrs old
2 yrs old
3 yrs old
4 yrs old
5 yrs old
6 yrs old
7 yrs old
8 yrs old
9 yrs old
10 yrs old
11 yrs old
12 yrs old
13 yrs old
14 yrs old
15 yrs old
16 yrs old
17 yrs old
18 yrs old
19 yrs old
20 yrs old
Is your water heater in the attic?
Select
Yes
No
Type of Pool
Select
Fenced
Unfenced
Self-Locking Gate?
Select
Yes
No
Dive Board
Select
Yes
No
Slide
Select
Yes
No
Dog Breed
Any bite history?
Select
Yes
No
If yes, please give details:
Is there a covering on the trampoline?
Select
Yes
No
Are there any other unique features or circumstances about the home we should know?
Property Updates
Roof Updates
Partial or Complete?
Year Updated
Plumbing Updates
Partial or Complete?
Year Updated
Electrical Updates
Partial or Complete?
Year Updated
HVAC Updates
Partial or Complete?
Year Updated
Square Feet:
Number of Stories:
Number of Acres:
Occupancy:
Inside City Limits?
Yes
No
Primary
Yes
No
Seasonal/Secondary
Yes
No
Current Home Insurance
Current Insurance Company
Annual Premium
Policy Expiration Date
Current Insurance Deductible
Current Windstorm Deductible
Current All Other Perils Deductibles
Is your policy being renewed?
Select
Yes
No
Policy Renewal Comments
Have you had a Liability Claim in the last 5 years, paid or not?
Select
Yes
No
Have you had 2 or more reported losses in the last 3 years?
Select
Yes
No
Have you had a theft loss within the last 3 years?
Select
Yes
No
Have you had a loss of any kind of $15,000 or more within the last 3 years?
Select
Yes
No
Prior Carrier Information
New Purchase:
Yes
No
If yes, date of purchase:
MM slash DD slash YYYY
If no, previous carrier:
Expiration Date of Current Policy:
MM slash DD slash YYYY
Non-renewing?
Yes
No
If yes, reason:
First Mortgagee Information
Loan #
Name
Address
City
State
Zip
How many years at the property requesting a quote for?
If residing at property less than 3 years please give previous property address (Street, City, State, Zip)
Signature
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Name
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