Paulson Quote Form | BenefitSource Insurance Services

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Paulson Insurance Quote

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Name of Person Submitting the Form:*

First Last

Email of Person Submitting the Form:*

Phone of Person Submitting the Form:*

How did you hear about us?*

Quote Type*

Home Quote Form

Property Type*

Home

Condo

Secondary

Property Address*

Street Address City State ZIP Code

Year Purchased*

Year Built*

Square Feet of Your Home?*

Has your Roof Been Updated?*

Yes

If so, when?*

Has your Heating System been Updated?*

Yes

If so, when?*

What kind of Plumbing is in your home?*

Do you have at least 100 AMP Circuit breakers and no fuses?*

Is Your Home Vacant of for Sale?*

Vacant

For Sale

Neither

Is There Existing Damage to Your Home?*

Yes

Custom or Designer Materials In:

Kitchen

Bathrooms

Previous Address

If you have owned this property less than 3 years, what is your prior address?

Street Address City State ZIP Code

Relationship Status*

Date of Birth*

Occupation*

If applicable, Spouse/Partner DOB

Spouse/Partner Name

First Last

Spouse/Partner Occupation

Any claims filed in the last 5 years?*

Yes

Describe nature and date of claim*

Any special High Value items you're concerned about? (Jewelry, art work, furs, etc)*

Yes

What Kind of High Value Items and What is the Value?*

Sprinkler system inside the home?*

Yes

If so, is the system:*

Full

Partial

Is the property in a gated community?*

Yes

If gated, is it guard gated?*

Yes

Burglar and Fire System Connection*

Are they connected to a monitoring company?

Yes

If yes, who is the monitoring vendor?*

Do you have any of the following?*

How Many Solar Panels?*

Do you have any of the following?*

Do you have a trampoline?*

Yes

If so, does it have a safety net?*

Yes

Do you have dogs?*

Yes

If so, what breeds?*

Do you use this property for AIRBNB/VRBO or student housing for a college?*

Do you have any of the following polices?*

Earthquake

Flood

Umbrella

None

Term Life Insurance*

Do you have term life insurance outside your employer that is at least ten times your annual income?

Yes

If so, how long have you had the policy?*

Auto Quote Form

Driver Count*

How many drivers are insured on your policy?

Home Address*

Street Address City State ZIP Code

Driver #1

Name*

First Last

Date of Birth*

Driver's License #*

Age First Licensed*

Any driving violations or accidents? Explain*

Sex*

Male

Female

Marital Status*

Married

Unmarried

Widowed

Widower

Occupation*

Work/School Address*

Name of Business/School Street Address City State ZIP Code

Driver #2

Name*

First Last

Date of Birth*

Driver's License #*

Age First Licensed*

Any driving violations or accidents? Explain*

Sex*

Male

Female

Marital Status*

Married

Unmarried

Widowed

Widower

Occupation*

Work/School Address*

Name of Business/School Street Address City State ZIP Code

Driver #3

Name*

First Last

Date of Birth*

Driver's License #*

Age First Licensed*

Any driving violations or accidents? Explain*

Sex*

Male

Female

Marital Status*

Married

Unmarried

Widowed

Widower

Occupation*

Work/School Address*

Name of Business/School Street Address City State ZIP Code

Driver #4

Name*

First Last

Date of Birth*

Driver's License #*

Age First Licensed*

Any driving violations or accidents? Explain*

Sex*

Male

Female

Marital Status*

Married

Unmarried

Widowed

Widower

Occupation*

Work/School Address*

Name of Business/School Street Address City State ZIP Code

Driver #5

Name*

First Last

Date of Birth*

Driver's License #*

Age First Licensed*

Any driving violations or accidents? Explain*

Sex*

Male

Female

Marital Status*

Married

Unmarried

Widowed

Widower

Occupation*

Work/School Address*

Name of Business/School Street Address City State ZIP Code

Driver #6

Name*

First Last

Date of Birth*

Driver's License #*

Age First Licensed*

Any driving violations or accidents? Explain*

Sex*

Male

Female

Marital Status*

Married

Unmarried

Widowed

Widower

Occupation*

Work/School Address*

Name of Business/School Street Address City State ZIP Code

Auto Identification

Insured Vehicles*

How many insured vehicles to you have on your auto insurance policy?

Vehicle #1

Year*

Make*

Model*

VIN #*

Use*

Commute

Pleasure

Business

Miles Driven Per Year*

Miles Driven One Way to Work?*

Primary Driver*

First Last

Aftermarket Options*

Do you have additional aftermarket equipment?

Yes

If so, which auto, type of equipment, and value?*

Years With Provider*

How many years have you been with your current auto insurance company?

Do you have an umbrella insurance policy?*

Yes

Do you have an auto provided by your employer?*

Yes

Do you have a AAA membership?*

Yes

Term Life Policy*

Do you have term life insurance outside of your employer that is at least ten times your annual income?

Yes

If so, how long have you had the term life?*

Discount Questions

Student Drivers*

Do any drivers on your policy under the age of 25 attend school full time and carry a 3.0 or above GPA?

Yes

Attendance Proof*

If so, can you provide a copy of the report card as proof of this discount?

Yes

College Grads*

Do any drivers have a degree from a 4 year accredited college or university located in the U.S.?

Yes

Graduation Proof*

Would you be able to provide a copy of the degree for the discount?

Yes

If so, list who, school name, and degree type:*

Rental Property Form

Property Address*

Street Address City State ZIP Code

Is the mailing address the same as the property address?*

Yes

Mailing Address*

Street Address City State ZIP Code

Year Purchased*

Owned Less Than 5 Years

If you have owned less than 5, what is your prior address?

Street Address City State ZIP Code

Do you have an HOA?*

Yes

Relationship Status*

Your Date of Birth*

Your Occupation*

Your spouse/partner Date of Birth*

Their Occupation*

Is there a tenant?*

Yes

If yes, are they full time or part time?*

Property Use*

Yes

Is the property used as a seasonal rental, such as AirBNB, Home Away?

Do you have a property management company?*

Yes

Is the property in a Trust, LLC, Corp or Partnership?*

Yes

Any Claims filed in last 5 years?*

Yes

If yes, describe and list approximate date:*

Do you have a Sprinkler System inside you home?*

Yes

If so, is the system:*

Full

Partial

Is the property located in a Gated Community?*

Yes

If gated, is it guard gated?*

Yes

Do you have any of the following?*

Pool

Jacuzzi

Both

Do you have Earth Quake insurance?*

Yes

Do you have Flood insurance?*

Yes

Renter's Form

Property Address*

Street Address City State ZIP Code

Your Date of Birth*

Select your personal property amount of coverage:*

Do you have any Jewelry that should be insured?*

Yes

If yes, describe and list its value:*

Do you have dogs?*

Yes

If so, what breeds?*

Any High Value items you’re concerned about?*

Yes

What Kind of High Value Items and What is the Value?*

Are there any special items that you're concerned about?*

Yes

Are you required to provide proof of insurance to your property manager?*

Yes

Motorcycle/ATV Form

How many Driver's operate your Motorcycle/ATV?*

Home Address*

Street Address City State ZIP Code

Driver #1

Name*

First Last

Date of Birth*

Driver's License #*

Sex*

Male

Female

Marital Status*

Married

Unmarried

Widowed

Widower

Age First Licensed*

Any driving violations or accidents?*

Yes

Driver #2

Name*

First Last

Date of Birth*

Driver's License #*

Sex*

Male

Female

Marital Status*

Married

Unmarried

Widowed

Widower

Age First Licensed*

Any driving violations or accidents?*

Yes

Driver #3

Name*

First Last

Date of Birth*

Driver's License #*

Sex*

Male

Female

Marital Status*

Married

Unmarried

Widowed

Widower

Age First Licensed*

Any driving violations or accidents?*

Yes

Driver #4

Name*

First Last

Date of Birth*

Driver's License #*

Sex*

Male

Female

Marital Status*

Married

Unmarried

Widowed

Widower

Age First Licensed*

Any driving violations or accidents?*

Yes

Driver #5

Name*

First Last

Date of Birth*

Driver's License #*

Sex*

Male

Female

Marital Status*

Married

Unmarried

Widowed

Widower

Age First Licensed*

Any driving violations or accidents?*

Yes

Driver #6

Name*

First Last

Date of Birth*

Driver's License #*

Sex*

Male

Female

Marital Status*

Married

Do you have additional aftermarket equipment?*

Yes

If so, how much aftermarket equipment?*

Do you have an Umbrella insurance policy?*

Yes

Boat Form

Home Address*

Street Address City State ZIP Code

Year*

Make*

Model*

Hull #*

Length*

Motor Style

Inboard

Outboard

Horse Power*

Cost New*

Current Value*

Do you have separate towing coverage?*

Yes

Do you have scheduled equipment?*

Yes

Years of Operating Experience:*

Do you have any marine certifications?*

Yes

Where is it stored?*

Street Address City State ZIP Code

Is it stored in a secured or fenced in area?*

Yes

Motor Home/Travel Trailer Form

How many Driver's operate your Motor Home?*

Home Address*

Street Address City State ZIP Code

Driver #1

Name*

First Last

Date of Birth*

Driver's License #*

Sex*

Male

Female

Marital Status*

Married

Unmarried

Widowed

Widower

Age First Licensed*

Any Driving violations or accidents?*

Yes

Driver #2

Name*

First Last

Date of Birth*

Driver's License #*

Sex*

Male

Female

Marital Status*

Married

Unmarried

Widowed

Widower

Age First Licensed*

Any Driving violations or accidents?*

Yes

Driver #3

Name*

First Last

Date of Birth*

Driver's License #*

Sex*

Male

Female

Marital Status*

Married

Unmarried

Widowed

Widower

Age First Licensed*

Any Driving violations or accidents?*

Yes

Driver #4

Name*

First Last

Date of Birth*

Driver's License #*

Sex*

Male

Female

Marital Status*

Married

Unmarried

Widowed

Widower

Age First Licensed*

Any Driving violations or accidents?*

Yes

Driver #5

Name*

First Last

Date of Birth*

Driver's License #*

Sex*

Male

Female

Marital Status*

Married

Unmarried

Widowed

Widower

Age First Licensed*

Any Driving violations or accidents?*

Yes

Driver #6

Name*

First Last

Date of Birth*

Driver's License #*

Sex*

Male

Female

Marital Status*

Married

Unmarried

Widowed

Widower

Age First Licensed*

Any Driving violations or accidents?*

Yes

Motor Home/Travel Trailer Identification

Number of Motor Home/Travel Trailer needing insured?*

Motor Home/Travel Trailer #1

Year*

Make*

Model*

VIN #*

Use*

Commute

Pleasure

Business

Miles Driven Per Year*

Primary Driver*

First Last

Motor Home/Travel Trailer #2

Year*

Make*

Model*

VIN #*

Use*

Commute

Pleasure

Business

Miles Driven Per Year*

Primary Driver*

First Last

Motor Home/Travel Trailer #3

Year*

Make*

Model*

VIN #*

Use*

Commute

Pleasure

Business

Miles Driven Per Year*

Primary Driver*

First Last

Motor Home/Travel Trailer #4

Year*

Make*

Model*

VIN #*

Use*

Commute

Pleasure

Business

Miles Driven Per Year*

Primary Driver*

First Last

Motor Home/Travel Trailer #5

Year*

Make*

Model*

VIN #*

Use*

Commute

Pleasure

Business

Miles Driven Per Year*

Primary Driver*

First Last

Motor Home/Travel Trailer #6

Year*

Make*

Model*

VIN #*

Use*

Commute

Pleasure

Business

Miles Driven Per Year*

Primary Driver*

First Last

Motor Home/Travel Trailer General Questions

Do you have additional aftermarket equipment?*

Yes

If so, how much what kind of aftermarket equipment?*

Where is this stored?*

Primary Home

Other

If "Other" list address:*

Street Address City State ZIP Code

Do you have an Umbrella insurance policy?*

Yes

Current Odometer*

General Document Uploads

Files

This is where you can upload your insurance declarations pages and any other relevant documents that are necessary for your quote request.

Drop files here or

Max. file size: 256 MB.