PERSONAL LINES QUOTE SHEET

Agent:	Today’s Date:
Effective Date:	Need By Date:

APPLICANT INFO:
Name:	# People in Household:
Address: (Include Street, City, County, State & Zip)
H) Phone:	C) Phone:	W) Phone:
Email Address:
Occupation:	Married: Y N	Domestic Partner: Y N
Applicant SSN:	Date of Birth:	Driver’s License No:
Spouse SSN:	Date of Birth:	Driver’s License No:
Paperless Options: Policy Billing Both

AUTOMOBILE:
LIMITS
Liability $	Med Pay $	Uninsured/Underinsured $	Comp & Collision Ded $
Accident Forgiveness Y N	Full Glass Y N	Towing $	Rental $	GAP Y N
Tracking Device Y N : Annual Miles:
DRIVER INFORMATION (please list all licensed drivers in household)
1	Name:	DOB:	DLN:
2	Name:	DOB:	DLN:
3	Name:	DOB:	DLN:
4	Name:	DOB:	DLN:
Good Student Discount Y N Applies to Driver #:	Driver Training Y N Applies to Driver #:	At School 100+ Miles Y N City, State & Zip Code:
Uber/Lyft Y N Applies to Car?
VEHICLE INFORMATION
YR:	Make & Model:	VIN#	# Mi to Work:
YR:	Make & Model:	VIN#	# Mi to Work:
YR:	Make & Model:	VIN#	# Mi to Work:
YR:	Make & Model:	VIN#	# Mi to Work:
ADDITIONAL INFORMATION
Tickets past 5 years (please give date & explanation):
Loan / Lease Y N	Name of Lender Lessee: Applicable Vehicle:
Previous Carrier & How Long? (if unverified, premium could be higher):
Previous Limits & Premium:
Losses for past 5 years (include date of loss & explanation):

HOMEOWNERS:
PRIMARY SECONDARY RENTAL VACANT CONDO GATED COMMUNITY
Previous Carrier – including how long with them & Effective Date (if unverified, premium could be higher):
Property Address (if different than above):
If less than a year, please provide previous address:
Yr Built:	# of Stories:	Square Feet (excluding basement):	Purchase Date:
Construction: (Brick, Veneer, Frame, Wood or Other)	Roof Type: (Asphalt, Tile, Architectural or Other)
Mortgage Billed Y N	Within 1,000 ft of Fire Hydrant: Y N
Heating/HVAC YR Updated	Plumbing YR Updated	Roofing Yr Updated	Electrical Yr Updated
Current Limit (or purchase price)	Deductible $
Deadbolt Y N	Fire Extinguisher Y N	Smoke Detector Y N
Alarm Y N	Type: Fire Burglar Centrally Monitored
Jewelry $	Furs $	Fine Arts $	Guns $
Water Backup $	Earthquake Y N
Losses for past 5 years (include date of loss & explanation)
Sump Pump Y N	Backup Battery Y N
Pool Y N	Fenced Y N	Diving Board Y N	Slide Y N
Pool Cover Y N	Locking Y N	Electric Y N
Trampoline Y N	Porch Y N	Porch Open Closed	Size Small Med Large
Foundation Slab (% ) Crawl Space (% ) Basement (% )
Finished Basement Y N	If Finished, %	Walkout Basement Y N
Deck Y N	Deck Size Small Med Large	Pets (Breed):
# Baths: Full ½	Garage Attached Detached	# of Cars
Wood Stove Y N	Fireplace Y N	# of	Wood Burning Gas Log
Flooring %: Hardwood: Carpet: Ceramic Tile: Vinyl:

UMBRELLA
Limit of Liability $	Excess UM/UIM Y N	If less than Limit, $
List all Board Positions Held:
Investment Property Owned Y N

RECREATIONAL VEHICLES
RV / Camper Y N	YR Make, Model & VIN#:	Current Value:
ATV Y N	YR Make, Model & VIN#:	Current Value:
Motorcycle Y N	YR Make & Model	VIN#
Actual Cash Value $	CC	Yrs Exp	MC License Endt Y N
Boat Y N	YR Make & Model
Length	Max Speed MPH	HP	Cost New $
Inboard Y N	Outboard Y N	VIN#
Golf Cart Y N	YR Make & Model	VIN#
Trailer Y N	YR Make & Model	VIN#
Loan / Lease Y N	Vehicle Applicable
Name of Lender/Lessee