Personal Insurance Renewal Review - Lee County Insurance

START YOUR QUOTE BELOW:

Enter some basic info below to start the quote process

Are you Interested in Personal or Business Quotes:(Required)

Business Information:

Business Name:(Required)

First and Last Name of Business Owner:(Required)

First Last

Phone Number:(Required)

Email Address:(Required)

Address of Business to be Insured:(Required)

City:(Required)

State:(Required)

Zip Code:(Required)

What Business Coverage is Needed, Select ALL That Apply:(Required)

Commercial Auto Insurance

Business Property Insurance

Commercial Trucking Insurance

Cyber Liability Insurance

General Liability Insurance

Restaurant Insurance

Workers Compensation Insurance

Commercial Auto Insurance:

Do you have a Commercial Auto Policy now without a 30 day Lapse in Coverage:(Required)

Previous Insurance Company:(Required)

Expiration Date:(Required)

Insurance Policy Premium:(Required)

How many Permitted drivers will be Operating the Vehicle (Including Yourself):(Required)

Driver 1:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Value of Violation:(Required)

Date of Violation:(Required)

Details of the Violation:(Required)

Driver 2:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Value of Violation:(Required)

Date of Violation:(Required)

Details of the Violation:(Required)

Driver 3:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Value of Violation:(Required)

Date of Violation:(Required)

Details of the Violation:(Required)

Driver 4:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Value of Violation:(Required)

Date of Violation:(Required)

Details of the Violation:(Required)

Driver 5:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Value of Violation:(Required)

Date of Violation:(Required)

Details of the Violation:(Required)

Driver 6:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Value of Violation:(Required)

Date of Violation:(Required)

Details of the Violation:(Required)

Vehicles:

How many Vehicles Should be Added to your Business Auto Policy:(Required)

Vehicle 1:

Year:(Required)

Make:(Required)

Model(Required)

Vehicle Identification Number:(Required)

Vehicle Usage:(Required)

Vehicle 2:

Year:(Required)

Make:(Required)

Model(Required)

Vehicle Identification Number:(Required)

Vehicle Usage:(Required)

Vehicle 3:

Year:(Required)

Make:(Required)

Model(Required)

Vehicle Identification Number:(Required)

Vehicle Usage:(Required)

Vehicle 4:

Year:(Required)

Make:(Required)

Model(Required)

Vehicle Identification Number:(Required)

Vehicle Usage:(Required)

Vehicle 5:

Year:(Required)

Make:(Required)

Model(Required)

Vehicle Identification Number:(Required)

Vehicle Usage:(Required)

Vehicle 6:

Year:(Required)

Make:(Required)

Model(Required)

Vehicle Identification Number:(Required)

Vehicle Usage:(Required)

Business Property Insurance:

Business Services Provided (Please Describe Below):(Required)

Value of Business Property:(Required)

Desired Total Liability Amount:(Required)

Expected Sales for the Year:(Required)

Have you had any Claims or Losses at this or any Other Addresses in the Past 5 years:(Required)

Value of Loss:(Required)

Date of Loss:(Required)

Details of Loss:(Required)

Commercial Trucking Insurance:

Business Structure:(Required)

Do you haul goods for:(Required)

What do you haul (Please use the Field below to Describe):(Required)

Are any Hazard Placards ever Required:(Required)

What Products or Numbers:(Required)

What is your Radius of Operations in Miles:(Required)

Is there any Permanently Attached Equipment or Hardware:(Required)

Total Approximate Value of Attached Equipment or Hardware:(Required)

Do you have a USDOT # Assigned:(Required)

USDOT Number:(Required)

Does the Operating Authority Require any of These Insurance Filings:(Required)

Do any of your Vehicles Travel Across State Lines:(Required)

States Traveled to:(Required)

Drivers:

How many Permitted drivers will be Operating the Vehicle (Including Yourself):(Required)

Driver 1:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License State:(Required)

Drivers License Number:(Required)

Any Claims or Violations:(Required)

Details of the Violation:(Required)

Date of Violation:(Required)

Value of Violation:(Required)

Driver 2:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License State:(Required)

Drivers License Number:(Required)

Any Claims or Violations:(Required)

Value of Violation:(Required)

Date of Violation:(Required)

Details of the Violation:(Required)

Driver 3:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License State:(Required)

Drivers License Number:(Required)

Any Claims or Violations:(Required)

Value of Violation:(Required)

Date of Violation:(Required)

Details of the Violation:(Required)

Driver 4:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License State:(Required)

Drivers License Number:(Required)

Any Claims or Violations:(Required)

Value of Violation:(Required)

Date of Violation:(Required)

Details of the Violation:(Required)

Cargo and Trailer Coverage:

Do you want Cargo Coverage:(Required)

What Limit:(Required)

What Deductible:(Required)

Would you like Trailer Interchange Coverage (If you would like Trailer Coverage, Please add it as a Vehicle Below):

What Deductible for Comp/Collision:(Required)

Vehicles:

How many Vehicles Should be Added to your Commercial Trucking Policy:(Required)

Vehicle 1:

Year:(Required)

Make:(Required)

Model(Required)

Vehicle Identification Number:(Required)

Vehicle Usage:(Required)

Vehicle 2:

Year:(Required)

Make:(Required)

Model(Required)

Vehicle Identification Number:(Required)

Vehicle Usage:(Required)

Vehicle 3:

Year:(Required)

Make:(Required)

Model(Required)

Vehicle Identification Number:(Required)

Vehicle Usage:(Required)

Vehicle 4:

Year:(Required)

Make:(Required)

Model(Required)

Vehicle Identification Number:(Required)

Vehicle Usage:(Required)

Cyber Liability Insurance:

Are you Currently Subject to:(Required)

PCI/DSS Compliance

HIPAA/HITECH Compliance

Neither

Do you use only chip-enabled cards or are your certified as PCI/DSS Compliant:(Required)

Do your Card Transactions Utilize End-to-End Encryption Technologies:(Required)

Do your Card Transactions Utilize Tokenization Technologies:(Required)

Are you Currently Compliant with HIPAA and HITECH Act Requirements:(Required)

Does your Business have Antivirus and/or Firewalls that are Updated at least Every Month:(Required)

Does your Business use 2FA/MFA for Access to Corporate Applications:(Required)

Is your Critical Business Information Backed-Up at least Once a Week:(Required)

Where is that Information Backed-Up to:(Required)

On-site

Offsite (Physical Storage)

Offsite (In the Cloud)

Data is Encrypted on:(Required)

Office Computers

Mobile Devices (Laptops, Cell Phones, Flash Drives, Tablets, etc.)

Networks

None

Do you have one or more of these Controls in Place:(Required)

Critical Software Patching Procedures

Formal Cyber Incident Response Plan

VPN's when Accessing Connections on Work Devices

Multifactor Authentication on Systems, Networks, and Emails:

None

Do you or Anyone Affiliated with you know of any act, error, omission, or breach of duty that is Listed Below:(Required)

Network Intrusion

Denial of Service Attack

Unauthorized loss of Personally Identifiable Information under your Control

None

Do you store, transmit, collect, or process any Customer or Client Biometric Data:(Required)

In the past five years, have you Experienced any claims related to a Data Breach, Extortion Threat, or any other Incident Involving a type of Fraud or Criminal Act:(Required)

Has any Regulatory, Governmental, or Administrative action been Brought Against you due to your Handling of Sensitive Data(Required)

Do you Currently rely on Cloud Computing, Software-as-a-Service, or any other Outsourced Computer Hosting for Revenue-Generating Operations:(Required)

Do you Provide any Consumer Products or Services:(Required)

General Liability Insurance:

Desired Liability Amount:(Required)

Expected Sales for the Year:(Required)

Number of Years of Experience in your type of Business:(Required)

Number of Employees Total:(Required)

Number of Full-Time Employees:(Required)

Number of Part-Time Employees:(Required)

Do you have all Required Licenses or Permits:(Required)

Is all Work done in State:(Required)

Restaurant Insurance:

Type of Restaurant:(Required)

Opening Time of Operation:

Closing Time of Operation:

Gross Sales:(Required)

Food Sales:(Required)

Liquor Sales (If none, Please put a Zero in this Field):(Required)

Other Sales (If none, Please put a Zero in this Field):(Required)

Does the Applicant have Liquor Liability in Force:(Required)

Total Seating Capacity:(Required)

Is there any Table Service:(Required)

Does this Applicant rent out Spaces for Private Events, such as Weddings or Parties:(Required)

What is the Square Footage of the Rental Space:(Required)

Sales Generated from the Rental Space:(Required)

Is there a Grease Chute for the Grill:(Required)

How often is the Grease Chute Cleaned:(Required)

Are Deep fat Fryers Located more than 16" from an open Flame:(Required)

Do the Deep Fryers have Thermostats and High Temperature Limits:(Required)

Is all Cooking Equipment Located Beneath an Approved Hood/Duct System:(Required)

How often are the Hood and Duct Cleaned:(Required)

Are the Hood and Duct Cleaned by a Commercial Firm:(Required)

Is there an Automatic Fuel Shut-Off:(Required)

Are there Portable Fire Extinguishers:(Required)

What Number is Tagged on the Extinguisher:(Required)

Date Extinguisher was Tagged:(Required)

How Often are Refrigerator Compressors Inspected and Serviced:(Required)

Does the Restaurant have 2 means of Egress:(Required)

Is there a Fire Alarm:(Required)

Is the Alarm:(Required)

Is there a Burglar Alarm:(Required)

Is the Alarm:(Required)

Is there any Delivery Service:(Required)

How is the Delivery Service Carried Out:(Required)

If Other, Please Explain Here:(Required)

Delivery Service Done by:(Required)

If you Offer a Catering Service, is it:(Required)

What Preparation and Sanitation Procedures are Followed to Prevent Foodborne Illness:(Required)

Has the Applicant been Cited for any Health Code Violations:(Required)

Please Provide Citation or Violation Details:(Required)

What Controls are in Place to Avoid Over-Serving of Alcohol or Distribution to Minors:(Required)

Do Bartenders have TIPS(Training for Intervention Procedures) Training:(Required)

Has the Applicant been Cited for Violations of Beverage Laws:(Required)

Please Provide Citation or Violation Details:(Required)

Please Indicate any Entertainment Provided:(Required)

Live Music

Dance Floor

Karaoke

Arcade Games

Amusement Devices

Other

Please Provide Details about any Amusement Devices:(Required)

Please Provide Details of any Other Entertainment:(Required)

Is there a Valet Parking Service:(Required)

Is there a Separate Insurance for the Valet Parking Exposure:(Required)

Are any Bouncers/Security Personnel Employed or Contracted:(Required)

Are all Employees References Checked Prior to Hiring:(Required)

Workers Compensation Insurance:

Is there any Framing or Construction of new Buildings or Additions:(Required)

Is there any new Construction in Multi-Home/Tract Home, Condo, Townhouse, Apartments, or Co-Ops:(Required)

Estimated Percentage of work Subcontracted out to Others:(Required)

Years of Industry Experience:(Required)

Do you Perform any Roofing work:(Required)

Do you Perform any Exterior work above the height of 3 Stories:(Required)

Estimated Gross Revenue that will be Generated for the next 12 Months:(Required)

Total Amount of Desired Coverage:(Required)

Number of Full-Time Employees:(Required)

Number of Part-Time Employees:(Required)

Estimated Total Annual Payroll (Excluding Owners or Subcontractors):(Required)

Estimated Annual Payroll for the Business Owner for the next 12 Months:(Required)

Estimated Annual Payroll for the Subcontractors for the next 12 Months:(Required)

Personal Information:

First and Last Name:(Required)

First Last

Cell Phone Number:(Required)

Email Address:(Required)

Address:(Required)

City:(Required)

State:(Required)

Zip Code:(Required)

Coverage:

What Personal Coverage is Needed. Select ALL That Apply:(Required)

Mobile/Manufactured Home Insurance:

Manufacturer of Mobile/Manufactured Home:

Name of Park or Community:

Mobile Home Usage:(Required)

Year Home was Originally Built:(Required)

Do you know the Size of your Mobile/Manufactured Home:(Required)

Length of Mobile/Manufactured Home (in Feet):(Required)

Width of Mobile/Manufactured Home (in Feet):(Required)

Type of Roof:(Required)

Year of Last roof Replacement:(Required)

Mobile/Manufactured Home Attachments:

Do you have a Carport:(Required)

Carport Length (in Feet):(Required)

Carport Width (in Feet):(Required)

Do you have an Enclosed Garage:(Required)

Enclosed Garage Length (in Feet):(Required)

Enclosed Garage Width (in Feet):(Required)

Do you have a Screen room:(Required)

Screen Room Length (in Feet):(Required)

Screen Room Width (in Feet):(Required)

Do you have a Weather Tight room:(Required)

Weather Tight Room Length (in Feet):(Required)

Weather Tight Room Width (in Feet):(Required)

Do you have a Shed:(Required)

Shed Length (in Feet):(Required)

Shed Width (in Feet):(Required)

Auto Insurance:

Do you have an Auto Policy now without a 30 day Lapse in Coverage:(Required)

Previous Insurance Company:(Required)

Expiration Date:(Required)

Insurance Policy Premium:(Required)

Drivers:

How many Permitted drivers will be Operating the Vehicle (Including Yourself):(Required)

Driver 1:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Value of Violation:(Required)

Date of Violation:(Required)

Details of the Violation:(Required)

Driver 2:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Value of Violation:(Required)

Date of Violation:(Required)

Details of the Violation:(Required)

Driver 3:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Value of Violation:(Required)

Date of Violation:(Required)

Details of the Violation:(Required)

Driver 4:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Value of Violation:(Required)

Date of Violation:(Required)

Details of the Violation:(Required)

Driver 5:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Value of Violation:(Required)

Date of Violation:(Required)

Details of the Violation:(Required)

Driver 6:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Value of Violation:(Required)

Date of Violation:(Required)

Details of the Violation:(Required)

Vehicles:

How many Vehicles Should be Added to your Auto Policy:(Required)

Vehicle 1:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Identification Number:(Required)

Vehicle Usage:(Required)

Vehicle 2:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Identification Number:(Required)

Vehicle Usage:(Required)

Vehicle 3:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Identification Number:(Required)

Vehicle Usage:(Required)

Vehicle 4:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Identification Number:(Required)

Vehicle Usage:(Required)

Vehicle 5:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Identification Number:(Required)

Vehicle Usage:(Required)

Vehicle 6:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Identification Number:(Required)

Vehicle Usage:(Required)

Homeowners Insurance:

Home Usage:(Required)

Select One(Required)

Roof Shape:(Required)

Year of last Roof Replacement:(Required)

Have you had any Claims at this or any Address in the past 5 years:(Required)

Date of Loss:(Required)

Value of Loss:(Required)

Details of Loss:(Required)

Condo Insurance:

Condo Association Name:(Required)

Address of Condo Unit(s) to be Insured:(Required)

City:(Required)

State:(Required)

Zip Code:(Required)

Condo Usage:(Required)

Have you had any Claims at this or any Address in the past 5 years:(Required)

Date of Loss:(Required)

Value of Loss:(Required)

Details of Loss:(Required)

Number of Units in the Building:(Required)

Number of Floors in Building:(Required)

Is there a Sprinkler System in the Building:(Required)

Do you have a copy of the Wind Mitigation Inspection Report (If so, Please use the File upload at the Bottom of the page to Send it our way):(Required)

All-Terrain Vehicle Insurance:

Engine Size (cc):(Required)

Do you have an ATV Policy now without a 30 day Lapse in Coverage:(Required)

Name of Other Provider:(Required)

Expiration Date:(Required)

Yearly Estimated Premium:(Required)

Riders:

How many Permitted drivers will be Operating the Vehicle (Including Yourself):(Required)

Rider 1:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Value of Violation:(Required)

Date of Violation:(Required)

Details of the Violation:(Required)

Has this Rider Taken a Safety Course:(Required)

Date of Rider Safety Course:(Required)

Rider 2:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Value of Violation:(Required)

Date of Violation:(Required)

Details of the Violation:(Required)

Has this Rider Taken a Safety Course:(Required)

Date of Rider Safety Course:(Required)

Rider 3:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Value of Violation:(Required)

Date of Violation:(Required)

Details of the Violation:(Required)

Has this Rider Taken a Safety Course:(Required)

Date of Rider Safety Course:(Required)

All-Terrain Vehicles:

How many Vehicles Should be Added to your ATV Policy:(Required)

All-Terrain Vehicle 1:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Usage:(Required)

All-Terrain Vehicle 2:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Usage:(Required)

All-Terrain Vehicle 3:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Usage:(Required)

All-Terrain Vehicle 4:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Usage:(Required)

Watercraft/Boat Insurance:

Where is the Boat Stored:(Required)

How is the Boat Stored:(Required)

Number of Months out of a year Stored there:(Required)

Are you the Original Owner:(Required)

Original Purchase Price:(Required)

Approximate Value:(Required)

Hull Identification Number:(Required)

Number of Engines:(Required)

Year of Engine 1:(Required)

Year of Engine 2:(Required)

Year of Engine 3:(Required)

Year of Engine 4:(Required)

Max Speed:(Required)

Total Horsepower of Engines:(Required)

Propulsion Type:(Required)

Hull Material:(Required)

Hull Length (in Feet):(Required)

Do you use a Trailer to Transport the Watercraft:(Required)

Trailer Year:(Required)

Trailer Make:(Required)

Would you like Trailer Coverage:(Required)

Collector Car Insurance:

How many Vehicles Should be Added to your Collector Car Insurance Policy:(Required)

Vehicle 1:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Identification Number:(Required)

What is the Vehicle Value (If you're unsure about this, you can just put the price you paid):(Required)

Are there any Modifications to the Vehicle:(Required)

What Modifications:(Required)

Increased Horsepower

Custom Paint

Custom Rims

Custom Frame

Is the Car Garage Kept, in a Barn, or Under a Carport:(Required)

Is the Vehicle used for Racing, Timed Events, AutoCross, or other High Performance Sports:(Required)

Is the Vehicle used as a Daily Driver for more than a month out of the year:(Required)

Vehicle 2:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Identification Number:(Required)

What is the Vehicle Value (If you're unsure about this, you can just put the price you paid):(Required)

Are there any Modifications to the Vehicle:(Required)

What Modifications:(Required)

Increased Horsepower

Custom Paint

Custom Rims

Custom Frame

Is the Car Garage Kept, in a Barn, or Under a Carport:(Required)

Is the Vehicle used for Racing, Timed Events, AutoCross, or other High Performance Sports:(Required)

Is the Vehicle used as a Daily Driver for more than a month out of the year:(Required)

Vehicle 3:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Identification Number:(Required)

What is the Vehicle Value (If you're unsure about this, you can just put the price you paid):(Required)

Are there any Modifications to the Vehicle:(Required)

What Modifications:(Required)

Increased Horsepower

Custom Paint

Custom Rims

Custom Frame

Is the Car Garage Kept, in a Barn, or Under a Carport:(Required)

Is the Vehicle used for Racing, Timed Events, AutoCross, or other High Performance Sports:(Required)

Is the Vehicle used as a Daily Driver for more than a month out of the year:(Required)

Vehicle 4:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Identification Number:(Required)

What is the Vehicle Value (If you're unsure about this, you can just put the price you paid):(Required)

Are there any Modifications to the Vehicle:(Required)

What Modifications:(Required)

Increased Horsepower

Custom Paint

Custom Rims

Custom Frame

Is the Car Garage Kept, in a Barn, or Under a Carport:(Required)

Is the Vehicle used for Racing, Timed Events, AutoCross, or other High Performance Sports:(Required)

Is the Vehicle used as a Daily Driver for more than a month out of the year:(Required)

Flood Insurance:

Building Type:(Required)

If Other, Please Describe here:(Required)

Value of Building:(Required)

Value of Contents:(Required)

How is the Property Occupied:(Required)

How many days out of the year does the Owner Occupy the Property:(Required)

Do you have a Copy of the the Elevation Certificate (If so, Please use the File Upload at the Bottom of the page to get it to us):(Required)

Is this a new Purchase:(Required)

What year was the Property Purchased:(Required)

Do you have a Flood Policy now without a 30 day Lapse in Coverage:(Required)

Prior Provider Name:(Required)

Closing Date:(Required)

Estimated Yearly Premium for Prior Provider:(Required)

Has there been any Claims or Losses in the past 6 Months at this or any Other Address:(Required)

Value of Loss:(Required)

Closing Date:(Required)

Details of Loss:(Required)

Motorcycle Insurance:

Engine Size (cc):(Required)

Do you have a Motorcycle Policy now without a 30 day Lapse in Coverage:(Required)

Name of Other Coverage Provider:(Required)

Expiration Date:(Required)

Estimated Yearly Premium:(Required)

Riders:

How many Permitted drivers will be Operating the Vehicle (Including Yourself):(Required)

Rider 1:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Value of Violation:(Required)

Date of Violation:(Required)

Details of the Violation:(Required)

Has this Rider Taken a Safety Course:(Required)

Date of Rider Safety Course:(Required)

Rider 2:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Details of the Violation:(Required)

Date of Violation:(Required)

Value of Violation:(Required)

Has this Rider Taken a Safety Course:(Required)

Date of Rider Safety Course:(Required)

Rider 3:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Claims or Violations:(Required)

Details of the Violation:(Required)

Date of Violation:(Required)

Value of Violation:(Required)

Has this Rider Taken a Safety Course:(Required)

Date of Rider Safety Course:(Required)

Motorcycles:

How many Vehicles Should be Added to your Motorcycle Policy:(Required)

Motorcycle 1:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Usage:(Required)

Motorcycle 2:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Usage:(Required)

Motorcycle 3:

Year:(Required)

Make:(Required)

Model:(Required)

Vehicle Usage:(Required)

RV/Motorhome Insurance:

Year of Motorhome:(Required)

Make of Motorhome:(Required)

Approximate Value of Motorhome:(Required)

Vehicle Identification Number:(Required)

Anti-Theft:(Required)

Length of Motorhome (in Feet):(Required)

Motorhome Permanent or Movable:(Required)

About how many days out of the year do you stay in the RV:(Required)

How many Permitted drivers will be Operating the Vehicle (Including Yourself):(Required)

Driver 1:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Violations or Claims:(Required)

Total Cost of Violation:(Required)

Date of Violation:(Required)

Details of the Violation(Required)

Driver 2:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Violations or Claims:(Required)

Total Cost of Violation:(Required)

Date of Violation:(Required)

Details of the Violation(Required)

Driver 3:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Violations or Claims:(Required)

Total Cost of Violation:(Required)

Date of Violation:(Required)

Details of the Violation(Required)

Driver 4:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Violations or Claims:(Required)

Total Cost of Violation:(Required)

Date of Violation:(Required)

Details of the Violation(Required)

Driver 5:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Violations or Claims:(Required)

Total Cost of Violation:(Required)

Date of Violation:(Required)

Details of the Violation(Required)

Renters Insurance:

Type of Housing:(Required)

Value of all Personal Property:(Required)

Do you have a Renters Policy now without a 30 day Lapse in Coverage:(Required)

Name of Other Renter Coverage Provider:(Required)

Expiration Date of Renter Coverage:(Required)

Estimated Yearly Premium:(Required)

Have you had any Claims or Losses in the Past 5 years:(Required)

Value of Loss:(Required)

Date of Loss:(Required)

Details of Loss:(Required)

Golf Cart Insurance:

What type of Golf Cart is it:(Required)

Make:(Required)

Seat Belt:(Required)

Max Speed:(Required)

How many Permitted drivers will be Operating the Vehicle (Including Yourself):(Required)

Driver 1:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Accidents, Tickets or Claims:(Required)

Total Cost of Violation:(Required)

When did the Violation Occur:(Required)

What Caused the Violation:(Required)

Driver 2:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Accidents, Tickets or Claims:(Required)

Total Cost of Violation:(Required)

When did the Violation Occur:(Required)

What Caused the Violation:(Required)

Driver 3:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Accidents, Tickets or Claims:(Required)

Total Cost of Violation:(Required)

When did the Violation Occur:(Required)

What Caused the Violation:(Required)

Driver 4:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Accidents, Tickets or Claims:(Required)

Total Cost of Violation:(Required)

When did the Violation Occur:(Required)

What Caused the Violation:(Required)

Driver 5:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Any Accidents, Tickets or Claims:(Required)

Total Cost of Violation:(Required)

When did the Violation Occur:(Required)

What Caused the Violation:(Required)

Golf Cart Information:

Is the Cart kept in the State of Residence for more than 6 months out of the year:(Required)

Is the Cart ever used by Short Term Renters on the Property:(Required)

Is there any Additional Optional Equipment:(Required)

Original Purchase Price:(Required)

Approximate Actual Cash Value:(Required)

Estimated Total Approximate Value of Optional Equipment:(Required)

Umbrella Insurance:

How many Motorized Vehicles Licensed for road use are Owned, Leased, Rented, or Regularly Operated by you or any Member of your Household (Do not Include Antique Vehicles or Collector Cars here):(Required)

How many Residential Properties are owned or rented by you or any Member of your Household (1-4 Family Units is 1 Property; Do not Include Properties Covered by a Commercial General Liability Policy):(Required)

How many Watercraft, OTHER than Canoes, Jet Skis, Waverunners, or other Personal Watercraft are owned or Regularly Operated by you or any Member of your Household:(Required)

How many Jet Skis, Waverunners, or Personal Watercraft are owned or Regularly Operated by you or any Member of your Household:(Required)

How many Drivers will be Operating Vehicles:(Required)

How many Drivers are under the age of 22 (Include Driver's with a Learner's Permit or Valid Driver's License):(Required)

How many Drivers are the age of 70 or over (Include Drivers with a Learner's Permit or Valid Driver's License):(Required)

How many total moving Violations have all drivers had Within the last 3 years (Include DWI/DUI incidents within the last 5 years):(Required)

How many at-fault Accidents have all drivers had in the last 3 years:(Required)

How many Antique, Classic, or Collectible Vehicles are Owned (Titled or Registered to) by you or any Member of your Household:(Required)

How many Residential Properties owned or rented by you or any member of your Household are Located outside Canada, Puerto Rico, or the U.S. (Including U.S. Territories and Possessions):(Required)

How many Acres of land do you or any Member of your Household own or lease (Including Partial Ownership; Do not Include land Covered by a Commercial General Liability Policy):(Required)

How many Driving Incidents have all drivers ages 21 and under and/or 80 and over had within the last 3 years:(Required)

How many arrests, citations, or license suspensions for driving under the Influence of Alcohol/Drugs and/or driving while Intoxicated and/or other Alcohol/Drug related Incidents have all Drivers had in the last 5 years:(Required)

Have you or any other driver had an Arrest, Citation, or Conviction for Reckless Driving, Careless Driving (with 4 points), Negligent Driving, and/or had a Driver's License Suspended, Revoked, or Refused in the last 5 years (for Reasons other than Driving under the Influence of Alcohol or Drugs):(Required)

Have you or any Member of your Household been Indicted, Charged with, or Convicted of a felony within the last 5 years:(Required)

Do you or any Member of your Household have an Occupation of a Professional Entertainer, Athlete, or Media Personality:(Required)

Has any one Driver had more than 3 moving Violations within the last 3 years (Include DWI/DUI Incidents within the last 5 years):(Required)

Has any one Driver ages 21 and under or 80 and over had more than one Driving Incident within the past 3 years:(Required)

What type of Liability Limits are Desired:(Required)

How many Licensed Drivers will be Operating any Vehicles:(Required)

Driver 1:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Relationship to the Applicant:(Required)

Number of Violations 3 years (Including DWI/DUI 5 years/3 years in MT):(Required)

Number of At-Fault Accidents (3 years):(Required)

Driver 2:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Relationship to the Applicant:(Required)

Number of Violations 3 years (Including DWI/DUI 5 years/3 years in MT):(Required)

Number of At-Fault Accidents (3 years):(Required)

Driver 3:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Relationship to the Applicant:(Required)

Number of Violations 3 years (Including DWI/DUI 5 years/3 years in MT):(Required)

Number of At-Fault Accidents (3 years):(Required)

Driver 4:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Relationship to the Applicant:(Required)

Number of Violations 3 years (Including DWI/DUI 5 years/3 years in MT):(Required)

Number of At-Fault Accidents (3 years):(Required)

Driver 5:

Name:(Required)

First Last

Date of Birth:(Required)

Drivers License Number:(Required)

Drivers License State:(Required)

Relationship to the Applicant:(Required)

Number of Violations 3 years (Including DWI/DUI 5 years/3 years in MT):(Required)

Wedding Insurance:

How many Days of Coverage do you Need:(Required)

Event Start Date:(Required)

Event End Date:(Required)

Number of Guests Attending:(Required)

Are there any Amusement Devices, Rides or Animals, or other Entertainment Options:(Required)

Have You or Anyone Attending the Event had More than 1 Event Claim Over $10,000 in the Past 5 Years(Required)

Will You or Anyone at the Event be Operating a Golf Cart, ATV, or a UTV:(Required)

Alcohol Coverage:(Required)

Coverage Limit:(Required)

Medical Payments:(Required)

Deductible:(Required)

Would you also like Wedding Cancellation Coverage (If you would, your Scheduled Event Date must be more than 7 Days Away):(Required)

Location Name:(Required)

Street Address of Event:(Required)

City:(Required)

Where is your Event Located:(Required)

Zip Code:(Required)

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John Doe

Customer since 1997

We got twice the coverage and saved 40% on our annual costs. Well worth the time to call these folks!

John Doe

Customer since 1997

We got twice the coverage and saved 40% on our annual costs. Well worth the time to call these folks!