Underwriting Questions - State Insurance Agency

General Info:
Name (As it should appear on your policy)*
Date of Birth*
Property Street Address*
City*
Zip Code*
Mailing Address
- Check this box to include a mailing address (if different than above)
Mailing Address*
| Please include street, unit, city & zip |
Phone Number*
Email*
Number of household members*
Please upload your current policy or inspections (if available)
Drop files here or
What type of coverage would you like us to quote?
- Home
- Auto
- Boat
- Liability umbrella
Additional Comments:
Submitted by:*
Home Info:
Is the home a new purchase?
- Yes
What is the expected closing date?*
Date Format: MM slash DD slash YYYY
Is the home a foreclosure or short sale?*
- Foreclosure
- Short Sale
- N/A
Occupancy Type*
Use of property*
Type of home*
Construction type*
Foundation type*
Year built*
Please enter a number from 1800 to 2020.
Square footage under air*
Number of stories*
Roof type*
Year roof last replaced (if applicable)
Do you own a dog?*
What is the breed of the dog?*
Do you have a trampoline?*
Do you have a pool?*
Is pool protected by a screen enclosure or permanent fence?*
Pool slide or diving board?*
Monitored burglar and fire alarm?*
Gated community?*
Any claims in the past 3 years at this or any other location?*
Any Bankruptcy, lien, repossessions or judgements in the past 5 years?*
Current Insurance Company?*
Expiration Date?*
Date Format: MM slash DD slash YYYY
Would you like a flood insurance quote?*
Upload a copy of current policy declarations page or answer questions below:
Dwelling Coverage:
Contents Coverage:
All Other Peril Deductible:
Hurricane Deductible:
Screen Enclosure?
Auto Info:
How many drivers?*
How many vehicles?*
Driver #1
Driver's Name*
Married?*
Drivers License #*
Occupation*
Highest Education Completed?*
Tickets or Accidents in past 5 years?*
Driver #2
Driver's Name*
Date of Birth*
Married?*
Drivers License #*
Occupation*
Highest Education Completed?*
Tickets or Accidents in past 5 years?*
Driver #3
Driver's Name*
Date of Birth*
Married?*
Drivers License #*
Occupation*
Highest Education Completed?*
Tickets or Accidents in past 5 years?*
Driver #4
Driver's Name*
Date of Birth*
Married?*
Drivers License #*
Occupation*
Highest Education Completed?*
Tickets or Accidents in past 5 years?*
Driver #5
Driver's Name*
Date of Birth*
Married?*
Drivers License #*
Occupation*
Highest Education Completed?*
Tickets or Accidents in past 5 years?*
Driver #6
Driver's Name*
Date of Birth*
Married?*
Drivers License #*
Occupation*
Highest Education Completed?*
Tickets or Accidents in past 5 years?*
Vehicle #1
Year*
Make*
Model*
VIN # (optional)
Annual miles driven*
Use of vehicle*
How many miles one way to work (if applicable)*
Collision Deductible*
Comprehensive Deductible*
Vehicle #2
Year*
Make*
Model*
VIN # (optional)
Annual miles driven*
Use of vehicle*
How many miles one way to work (if applicable)*
Collision Deductible*
Comprehensive Deductible*
Vehicle #3
Year*
Make*
Model*
VIN # (optional)
Annual miles driven*
Use of vehicle*
How many miles one way to work (if applicable)*
Collision Deductible*
Comprehensive Deductible*
Vehicle #4
Year*
Make*
Model*
VIN # (optional)
Annual miles driven*
Use of vehicle*
How many miles one way to work (if applicable)*
Collision Deductible*
Comprehensive Deductible*
Vehicle #5
Year*
Make*
Model*
VIN # (optional)
Annual miles driven*
Use of vehicle*
How many miles one way to work (if applicable)*
Collision Deductible*
Comprehensive Deductible*
Current Coverage or upload file below
Upload current policy declarations page (if available)
Drop files here or
Bodily Injury (x1000)
Property Damage (x1000)
Medical Payments
Uninsured Motorist (x1000)
Car rental*
Towing*
Current Insurance Carrier*
Years with prior carrier*
Expiration date*
Date Format: MM slash DD slash YYYY
Have you or anyone on your policy had a Personal Injury Protection (PIP) claim in the past 5 years?*
Are you an AARP member?*
Do you have a liability umbrella policy in place?*
Would you like an umbrella policy quote?*
Boat Info:
Year*
Make*
Model*
Length*
Number of engines*
Total horsepower*
Is boat ever used for business purpose?*
More than 50 miles offshore?*
Boater safety course?*
Any claims in past 5 years?*
Liability umbrella Info:
Number of properties owned*
Number of automobiles owned*
Number of recreational vehicles*
Coverage limit requested?*
Any claims in the last 5 years?*
Date of Birth*

General Info:

Home Info:

Auto Info:

Driver #1

Driver #2

Driver #3

Driver #4

Driver #5

Driver #6

Vehicle #1

Vehicle #2

Vehicle #3

Vehicle #4

Vehicle #5

Current Coverage or upload file below

Boat Info:

Liability umbrella Info: