Suzanne Fillerup Quote Form

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*

MM

DD

YYYY

Year Built*

MM

DD

YYYY

Square Feet of Your Home?*

Has your Roof Been Updated?*

Yes
No

If so, when?*

MM

DD

YYYY

Is Your Home Vacant of for Sale?*

Vacant
For Sale
Neither

Is There Existing Damage to Your Home?*

Yes
No

Custom or Designer Materials In:

Kitchen
Bathrooms

Previous Address

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

Street Address City State ZIP Code

Do you have an HOA?*

Yes
No

Relationship Status*

Married
Domestic Partner
Single
Divorced
Widowed
Widower

Date of Birth*

MM

DD

YYYY

Occupation*

If applicable, Spouse/Partner DOB

MM

DD

YYYY

Spouse/Partner Occupation

Any claims filed in the last 5 years?*

Yes
No

Describe nature and date of claim*

Any special High Value items you're concerned about?*

Yes
No

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

Sprinkler system inside the home?*

Yes
No

If so, is the system:*

Full
Partial

Is the property in a gated community?*

Yes
No

If gated, is it guard gated?*

Yes
No

Burglar and Fire System Connection*

Are they connected to a monitoring company?

Yes
No

If yes, who is the monitoring vendor?*

Do you have any of the following?*

Pool
Jacuzzi
Water Slide
Diving Board
Solar Panels
None

How Many Solar Panels?*

Do you have any of the following?*

Live-In Nanny
Regular Service People
Tree House
Skate Board Ramps
Homes Based Business
Wood or Pellet Stove
Farming Operations
None

Do you have a trampoline?*

Yes
No

If so, does it have a safety net?*

Yes
No

Do you have dogs?*

Yes
No

If so, what breeds?*

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
No

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*

MM

DD

YYYY

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*

MM

DD

YYYY

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*

MM

DD

YYYY

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*

MM

DD

YYYY

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*

MM

DD

YYYY

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*

MM

DD

YYYY

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 #*

Current Odometer Reading*

Use*

Commute
Pleasure
Business

Miles Driven Per Year*

Miles Driven One Way to Work?*

Primary Driver*

First Last

Vehicle #2

Year*

Make*

Model*

VIN #*

Current Odometer Reading*

Use*

Commute
Pleasure
Business

Miles Driven Per Year*

Miles Driven One Way to Work?*

Primary Driver*

First Last

Vehicle #3

Year*

Make*

Model*

VIN #*

Current Odometer Reading*

Approximate Purchase Date*

MM

DD

YYYY

Use*

Commute
Pleasure
Business

Miles Driven Per Year*

Miles Driven One Way to Work?*

Primary Driver*

First Last

Vehicle #4

Year*

Make*

Model*

VIN #*

Current Odometer Reading*

Approximate Purchase Date*

MM

DD

YYYY

Use*

Commute
Pleasure
Business

Miles Driven Per Year*

Miles Driven One Way to Work?*

Primary Driver*

First Last

Vehicle #5

Year*

Make*

Model*

VIN #*

Current Odometer Reading*

Approximate Purchase Date*

MM

DD

YYYY

Use*

Commute
Pleasure
Business

Miles Driven Per Year*

Miles Driven One Way to Work?*

Primary Driver*

First Last

Vehicle #6

Year*

Make*

Model*

VIN #*

Current Odometer Reading*

Approximate Purchase Date*

MM

DD

YYYY

Use*

Commute
Pleasure
Business

Miles Driven Per Year*

Miles Driven One Way to Work?*

Primary Driver*

First Last

General Vehicle Questions

Aftermarket Options*

Do you have additional aftermarket equipment?

Yes
No

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
No

Do you have an auto provided by your employer?*

Yes
No

Do you have a AAA membership?*

Yes
No

Term Life Policy*

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

Yes
No

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
No

Attendance Proof*

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

Yes
No

College Grads*

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

Yes
No

Graduation Proof*

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

Yes
No

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
No

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
No

Relationship Status*

Your Date of Birth*

MM

DD

YYYY

Your Occupation*

Your spouse/partner Date of Birth*

MM

DD

YYYY

Their Occupation*

Is there a tenant?*

Yes
No

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

Property Use*

Yes
No

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

Do you have a property management company?*

Yes
No

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

Yes
No

Any Claims filed in last 5 years?*

Yes
No

If yes, describe and list approximate date:*

Do you have a Sprinkler System inside you home?*

Yes
No

If so, is the system:*

Full
Partial

Is the property located in a Gated Community?*

Yes
No

If gated, is it guard gated?*

Yes
No

Do you have any of the following?*

Pool
Jacuzzi
Both

Do you have Earth Quake insurance?*

Yes
No

Do you have Flood insurance?*

Yes
No

Renter's Form

Property Address*

Street Address City State ZIP Code

Your Date of Birth*

MM

DD

YYYY

Select your personal property amount of coverage:*

Do you have any Jewelry that should be insured?*

Yes
No

If yes, describe and list its value:*

Do you have dogs?*

Yes
No

If so, what breeds?*

Any High Value items you’re concerned about?*

Yes
No

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

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

Yes
No

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

Yes
No

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*

MM

DD

YYYY

Driver's License #*

Sex*

Male
Female

Marital Status*

Married
Unmarried
Widowed
Widower

Age First Licensed*

Any driving violations or accidents?*

Yes
No

Driver #2

Name*

First Last

Date of Birth*

MM

DD

YYYY

Driver's License #*

Sex*

Male
Female

Marital Status*

Married
Unmarried
Widowed
Widower

Age First Licensed*

Any driving violations or accidents?*

Yes
No

Driver #3

Name*

First Last

Date of Birth*

MM

DD

YYYY

Driver's License #*

Sex*

Male
Female

Marital Status*

Married
Unmarried
Widowed
Widower

Age First Licensed*

Any driving violations or accidents?*

Yes
No

Driver #4

Name*

First Last

Date of Birth*

MM

DD

YYYY

Driver's License #*

Sex*

Male
Female

Marital Status*

Married
Unmarried
Widowed
Widower

Age First Licensed*

Any driving violations or accidents?*

Yes
No

Driver #5

Name*

First Last

Date of Birth*

MM

DD

YYYY

Driver's License #*

Sex*

Male
Female

Marital Status*

Married
Unmarried
Widowed
Widower

Age First Licensed*

Any driving violations or accidents?*

Yes
No

Driver #6

Name*

First Last

Date of Birth*

MM

DD

YYYY

Driver's License #*

Sex*

Male
Female

Marital Status*

Married
Unmarried
Widowed
Widower

Age First Licensed*

Any driving violations or accidents?*

Yes
No

Primary Driver*

First Last

Motorcycle/ATV General Questions

Do you have additional aftermarket equipment?*

Yes
No

If so, how much aftermarket equipment?*

Do you have an Umbrella insurance policy?*

Yes
No

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
No

Do you have scheduled equipment?*

Yes
No

Years of Operating Experience:*

Do you have any marine certifications?*

Yes
No

Where is it stored?*

Street Address City State ZIP Code

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

Yes
No

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*

MM

DD

YYYY

Driver's License #*

Sex*

Male
Female

Marital Status*

Married
Unmarried
Widowed
Widower

Age First Licensed*

Any Driving violations or accidents?*

Yes
No

Driver #2

Name*

First Last

Date of Birth*

MM

DD

YYYY

Driver's License #*

Sex*

Male
Female

Marital Status*

Married
Unmarried
Widowed
Widower

Age First Licensed*

Any Driving violations or accidents?*

Yes
No

Driver #3

Name*

First Last

Date of Birth*

MM

DD

YYYY

Driver's License #*

Sex*

Male
Female

Marital Status*

Married
Unmarried
Widowed
Widower

Age First Licensed*

Any Driving violations or accidents?*

Yes
No

Driver #4

Name*

First Last

Date of Birth*

MM

DD

YYYY

Driver's License #*

Sex*

Male
Female

Marital Status*

Married
Unmarried
Widowed
Widower

Age First Licensed*

Any Driving violations or accidents?*

Yes
No

Driver #5

Name*

First Last

Date of Birth*

MM

DD

YYYY

Driver's License #*

Sex*

Male
Female

Marital Status*

Married
Unmarried
Widowed
Widower

Age First Licensed*

Any Driving violations or accidents?*

Yes
No

Driver #6

Name*

First Last

Date of Birth*

MM

DD

YYYY

Driver's License #*

Sex*

Male
Female

Marital Status*

Married
Unmarried
Widowed
Widower

Age First Licensed*

Any Driving violations or accidents?*

Yes
No

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
No

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

Where is this stored?*

Primary Home
Other

Of "Other" list address:*

Street Address City State ZIP Code

Do you have an Umbrella insurance policy?*

Yes
No

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

Email

This field is for validation purposes and should be left unchanged.