[Account Review Form] Please complete below: Do You Own A Home?(Required) Yes No Please answer the following questions:Name(Required) First Last What Is Your Address?(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What is your phone number? Spouse's phone number (if applicable)?(Required)What is your email? What is your spouse's email (if applicable)?(Required) What is/are your current occupations (s)?(Required)Is your home in a homeowners association?(Required) Yes No Is you home listed in a trust?(Required) Yes No If so, please list full wording of the Trust(Required)What is the age of your roof?(Required)Any detached structures? Sheds? Pools? Etc?(Required)Have you done any home improvements/renovations in the last couple years? If so, please explain and list rough cost of renovation.(Required)Is your basement finished? If so, what percentage?(Required)Do you have any income producing hobbies? If so, please explain.(Required)Are you comfortable with your existing limits for damage resulting from backed up drains or failed sump pumps?(Required) Yes No, please quote I am unsure of my limit, please contact me What carrier insures your vehicle (s)?(Required)Do you have life insurance? If so, where is the insurance through?(Required)Do you have an inventory of household possessions. If not, we recommend taking a video or keeping a list online of your major household possessions in the case of a total loss.(Required) Yes No Are you interested in a homeowners deductible of $2,500 or higher?(Required) Yes No Do you have an property you would like scheduled on your home policy? For example, Coin or stamp collections, jewelry, furs, guns, silverware, appraised antiques, appraised artwork, collectables, computers/electronics used in business, photography equipment, musical instruments?(Required)Please list all household members and their DOBs as well as their relation to you. Please indicate which members are drivers or non-drivers.(Required)NameDate Of BirthRelationDriver or Non Driver Add RemoveDoes anyone borrow your vehicle on a regular basis?(Required) Yes No Are your vehicles listed in a Trust?(Required) Yes No If so, please list exact wording of the Trust.(Required)Do you have any signs or business logos on your vehicles?(Required) Yes No How many miles do you drive to work every day? Pleasure, commute, or business use?(Required)Do you have any teens in the household using a Teen Monitoring App?(Required) Yes No If so, what app?(Required)Do you or anyone in the house use the vehicles for business use? For example, uber, lyft, shipt, etc?(Required) Yes No Do you drive a company car?(Required) Yes No Please list year, make, and model of each vehicle you insure as well as what coverage you would like.(Required)YearMakeModelComp and Collision Coverage? (type comp, collision, or both) Add RemoveDo you own any valuable items like jewelry, guns, antiques?(Required) Yes No If so, please list them:(Required)Do you own any ATVs boats, snowmobiles or similar?(Required) Yes No If so, please describe:(Required)I have questions on coverages, etc. Please reach out to me!(Required) Yes No Please answer the following questions:Name(Required) First Last What is your address?(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What is your phone number? Spouse's phone number (if applicable)?(Required) Add RemoveWhat is your email? What is your spouse's email (if applicable)?(Required) Add RemoveWhat is/are your current occupations (s)?(Required) Add RemovePlease list all household members and their DOBs as well as their relation to you. Please indicate which members are drivers or non-drivers.(Required)NameDate Of BirthRelationDriver or Non Driver Add RemoveDoes anyone borrow your vehicle on a regular basis?(Required) Yed No Are your vehicles listed in a Trust?(Required) Yes No If so, please list exact wording of the Trust(Required)Do you have any signs or business logos on your vehicles?(Required) Yes No How many miles do you drive to work every day? Pleasure, commute, or business use?(Required)Do you have any teens in the household using a Teen Monitoring App?(Required) Yes No If so, what app?(Required)Do you or anyone in the house use the vehicles for business use? For example, uber, lyft, shipt, etc?(Required) Yes No Do you drive a company car?(Required) Yes No Please list year, make, and model of each vehicle you insure as well as what coverage you would like.(Required)YearMakeModelComp and Collision Coverage? (type comp, collision, or both) Add RemoveDo you rent or live with a family member?(Required) Rent Live with family Other Do you own any valuable items like jewelry, guns, antiques(Required) Yes No If so, please list them:(Required)Do you own any ATVs boats, snowmobiles or similar?(Required) Yes No If so, please describe:(Required)
