Request Insurance Quotes – JMP Insurance Brokers

1Preliminary

2Personal Information

3Property Information

4Coverage Information

5Mortgagee/Additional Interest Information

6Claims Information

7Other Information

PRELIMINARY INFORMATION

Is this inquiry urgent?(Required)

Non-Urgent

Urgent (48hrs or Less)

Are you an existing client of JMP Insurance Brokers?(Required)

Yes

How did you hear about JMP Insurance Brokers?(Required)

If referred, please be so kind as to share their name so we may have the pleasure of thanking them.(Required)

Select an insurance type:(Required)

Personal Insurance

Commercial Insurance

What type of Personal Insurance are you interested in?(Required)

Please check all that apply.

Homeowners/Renters

Valuables

Motor Vehicles/Collector Cars

Umbrella/Excess Liability

Watercraft

Primary/Excess Flood

Life/Disability/Long-Term Care

What type of Home(s)?(Required)

Please check all that apply.

Condo/Co-Op

Renters/Tenants

City Home / Brownstone / Townhouse

Free-Standing Home

Rural Coastal Home

California / Seismic / Brush

What type of Commercial Insurance are you interested in? (Please check all that apply)(Required)

Business Owners Policies/General Liability & Property

Commercial Auto

Commercial Umbrella

Residential/Habitational Programs

Specialty Coverage

Worker's Compensation (WCO)/Disability

Group Health/Group Life

What type of Specialty Coverage are you interested in? (Please check all that apply)(Required)

Professional Liability - Errors & Omissions (E&O)

Directors & Officers (D&O)

Cyber Liability

Employment Practices (EPLI)

Crime

Fiduciary Liability/Bonds

PERSONAL INFORMATION

Requested Policy Effective Date:(Required)

MM slash DD slash YYYY

Expiration Date of Prior/Existing Coverage (If different from Effective Date):

FIRST NAMED-INSURED DETAILS

First Named-Insured as it should appear on Policy:(Required)

Prefix First Middle Last Suffix

Date of Birth:(Required)

Gender:(Required)

Mobile Phone:(Required)

By providing a telephone number and submitting the form you are consenting to be contacted by SMS text message. Message & data rates may apply. No mobile information will be shared with third parties/affiliates for marketing/promotional purposes.

Please confirm that this is a Mobile Phone:(Required)

Yes

Secondary Phone:

Secondary Phone Type:

Email:(Required)

Enter Email Confirm Email

Secondary Email:

Secondary Email Type:

Profession:(Required)

Employer:(Required)

Will you provide a Social Security Number?(Required)

Yes

Please enter Social Security Number (SSN):(Required)

Will you be providing your US Driver License details?(Required)

Yes

Note: Many carriers require Driver’s License details for Liability/Umbrella Coverages

State of Issuance:(Required)

Driver's License Number:(Required)

Expiration Date:(Required)

MM slash DD slash YYYY

Should a Second Named-Insured be listed on the Policy?(Required)

Yes

SECOND NAMED-INSURED

Second Named-Insured as it should appear on Policy:(Required)

Prefix First Middle Last Suffix

Date of Birth:(Required)

Gender:(Required)

Mobile Phone:(Required)

Please confirm that this is a Mobile Phone:

Yes

Secondary Phone:

Secondary Phone Type:

Primary Email:

Enter Email Confirm Email

Secondary Email:

Secondary Email Type:

Profession:(Required)

Employer:(Required)

Will you provide a Social Security Number (SSN)?(Required)

Yes

Please enter Social Security Number (SSN):(Required)

Will you be providing your US Driver License Details?(Required)

Yes

Note: Many Carriers require Driver’s License details for Liability/Umbrella Coverages

State of Issuance:(Required)

Driver's License Number:(Required)

Expiration Date:(Required)

MM slash DD slash YYYY

LLC / TRUST / ESTATE

Is the Property owned or being purchased in the name of a Trust or LLC?(Required)

Yes

What is the Property Ownership Interest?(Required)

Trust

LLC

Estate

Legal Name:(Required)

Tax ID:(Required)

Legal Address:(Required)

Address Line 1 Address Line 2 City State Zip Code

Date established/formed:(Required)

Month

Day

Year

Additional Trust Questions

Is the Trust Revocable or Irrevocable?(Required)

Revocable

Irrevocable

Why was the Trust established?(Required)

Who are the Trustees and Relationship to the Trust?(Required)

What are the asset holdings of the Trust?(Required)

Does the Trust engage in any business or activates which derive income?(Required)

Yes

Please describe:(Required)

Does the Trust have any employees?(Required)

Yes

Please list:(Required)

How many, their responsibilities, along with their gross annual payroll.

Additional LLC Questions

Why was the LLC established?(Required)

Who are the members of the LLC and what is there relationship to the Property being issued?(Required)

Does the LLC conduct any business?(Required)

Yes

Please describe the LLC's business operations:(Required)

Does the LLC have any employees?(Required)

Yes

How many employees does the LLC employ and what is their aggregate annual gross payroll?(Required)

Does the LLC own or plan to own any other properties and operate it as a real estate investment business?(Required)

Yes

Please describe:(Required)

Additional Estate Questions

Who is/are the Executor(s)?(Required)

Executor(s) full contact address(es):(Required)

Street Address Address Line 2 City State ZIP Code

Executor's primary email address:(Required)

Enter Email Confirm Email

Executor's mobile phone number:(Required)

Is the Property for sale or rent?(Required)

Sale

Rent

Is the Property furnished or unfurnished?(Required)

Furnished

Unfurnished

What is the estimated value of the furnishings?(Required)

Is the Property under renovation?(Required)

Yes

Trust Custodian Details

Custodian Name:(Required)

First Last

Address:(Required)

Street Address Address Line 2 City State ZIP Code

Trust US Tax ID:(Required)

PROPERTY INFORMATION - Renters/Tenants

What type of Property are you renting?(Required)

Property address for which you need insurance:(Required)

Address Line 1 Address Line 2 City State Zip Code

Is the mailing/billing address the same as the Property address to be insured?(Required)

Yes

Mailing/billing address:(Required)

Address Line 1 Address Line 2 City State ZIP Code

Year built?(Required)

Square Footage of Property:(Required)

Floor on which unit resides?(Required)

Elevator or walk-up?(Required)

Elevator

Walk-Up

Are there security cameras in the elevators?(Required)

Yes

Sprinklers in the unit?(Required)

Yes

PROPERTY INFORMATION - Condo/Co-Op

Is the property a Condo or Co-Op?(Required)

Condo

Co-Op

Property address for which you need insurance:(Required)

Address Line 1 Address Line 2 City State Zip Code

Is the mailing/billing address the same as the Property address to be insured?(Required)

Yes

Mailing/billing address:(Required)

Address Line 1 Address Line 2 City State Zipcode

Interior Square Footage of Property:(Required)

Exterior Square Footage of Property:

Year Built:(Required)

Number of Stories in Building:(Required)

Floor on which unit resides:(Required)

Sprinklers in the unit?(Required)

Yes

Doorman, virtual doorman or buzzer building?(Required)

Doorman

Virtual Doorman

Buzzer Building

Is the building staffed?(Required)

24-Hour Doorman

Part-Time Doorman

Do the elevators have cameras?(Required)

Yes

Are the elevators locked?(Required)

Yes

Type of heat:(Required)

Oil

Natural Gas

Electric

Where is the tank located?(Required)

Is the oil tank under an active maintenance contract?(Required)

Yes

What is the roof shape?(Required)

What is the roof covering type?(Required)

Year of the last complete updates to plumbing, electrical, roof and heat.

Plumbing:(Required)

Electrical:(Required)

Roof:(Required)

Heat:(Required)

Any canine residents in the household?(Required)

Yes

Please provide total number along with breed and bite history of each:(Required)

Please note that most insurance carriers do not insure owners/properties with the following canine breeds: Doberman Pinscher, Pit Bull, Rottweiler, Chow Chow, Wolf Dogs/Wolf Hybrids, Presa Canario (Canary Dog), Akita, Mastiff, Bullmastiff, American Bulldog.

Do you require primary flood insurance?(Required)

Yes

Is the Unit a primary or secondary residence?(Required)

Primary

Secondary

Will the Unit be rented-to-others (RTO)?(Required)

Yes

Will the Unit be occupied within 30 days of Policy issuance?(Required)

Yes

When will the Unit be occupied?(Required)

Are any renovations planned within the first 6-months after policy issuance?(Required)

Yes

Please describe the planned renovations:(Required)

Do you have a permanently-installed, bolted-down safe?(Required)

Yes

PROPERTY INFORMATION - City Homes / Brownstones / Townhouses

Address for which you need insurance:(Required)

Address Line 1 Address Line 2 City State Zip Code

Is the mailing/billing address the same as the Property address to be insured?(Required)

Yes

Mailing / billing address:(Required)

Address line 1 Address line 2 City State Zip Code

Owner occupied?(Required)

Yes

Year Built:(Required)

Construction type:(Required)

Number of stories:(Required)

Number of units:(Required)

Interior square footage:(Required)

Type of heat:(Required)

Oil

Natural Gas

Electric

Location of Tank:(Required)

Is the oil tank under active maintenance contract?(Required)

Yes

Year of the last complete updates to the plumbing, electrical, roof and heat.

Plumbing:(Required)

Electrical:(Required)

Roof:(Required)

Heat:(Required)

Roof shape:(Required)

Roof covering type:(Required)

Is the roof and gutters under an active maintenance contract?(Required)

Yes

Any working wood fireplaces / chimneys?(Required)

Yes

How many?(Required)

Are the fireplaces and chimneys under an active maintenance contract?(Required)

Yes

Any propane stoves?(Required)

Yes

Two forms of ingress / egress on every floor?(Required)

Yes

Lit exit signs in all common areas?(Required)

Yes

Fire extinguishers present on every floor?(Required)

Yes

One (1) for every 1,000 square feet of living space.

Smoke / carbon monoxide detectors on every floor?(Required)

Yes

One (1) for every 1,000 square feet of living space.

Is the building fully sprinklered?(Required)

Is there a basement?(Required)

Yes

Is the basement finished?(Required)

Yes

What is the square footage of the basement?(Required)

Does the basement currently have an active sump pump?(Required)

Yes

Does the basement currently have French drains?(Required)

Yes

Has the Property experienced basement flooding within the past 5 years?(Required)

Yes

Please describe each flood loss occurrence:(Required)

Is there an active centrally monitored alarm system for both fire and theft?(Required)

Enter Building - Each unit has its own active alarm system.

Owner's Suite Only

No Alarms

Does the Property have a flow-based water leak detection system tied into the central alarm system with automatic water shutoff?(Required)

Yes

Does the Property have low-temperature monitoring tied into the alarm system with automatic water shutoff?(Required)

Yes

Is there an active maintenance contract for sidewalk / walkway maintenance and repair?(Required)

Yes

Is there an active maintenance contract for ice / snow / sleet / debris removal?(Required)

Yes

Is there an active maintenance contract for waste management?(Required)

Yes

Is there a fire hydrant within 1,000 square feet of the Property?(Required)

Yes

Unknown

Is there a fire station within 5 miles of the Property?(Required)

Yes

Unknown

Any canine residents in the household?(Required)

Yes

Please provide a total number along with breed and bite history of each:(Required)

Does the Property require primary flood insurance?(Required)

Yes

Do you intend to move-in / live-in the Property within 30 days of closing?(Required)

Yes

Please describe:(Required)

Are there any renovations planned immediately after closing / policy issuance?(Required)

Yes

Please describe:(Required)

Do you have a permanently-installed, bolted-down safe?(Required)

Yes

PROPERTY INFORMATION - Free-Standing Home

Address for which you need insurance:(Required)

Address Line 1 Address Line 2 City State Zipcode

Is the mailing/billing address the same as the Property address to be insured?(Required)

Yes

Mailing/billing address:(Required)

Address Line 1 Address Line 2 City State Zipcode

Year Built:(Required)

Type of Construction:(Required)

Number of Stories:(Required)

Foundation Type:(Required)

Type of Heat:(Required)

Oil

Natural Gas

Electric

Where is the Tank?(Required)

Is Oil Tank under an active maintenance contract?(Required)

Yes

Roof Shape:(Required)

Roof Covering Type:(Required)

Are the roof and gutters under an active maintenance contract?(Required)

Yes

Year of the last complete updates to the plumbing, electrical, roof & heating:

Plumbing:(Required)

Electrical:(Required)

Roof:(Required)

Heat:(Required)

Any working wood fireplaces?(Required)

Yes

How Many?(Required)

Are the fireplaces and chimneys under an active maintenance contact?(Required)

Yes

Any propane stoves?(Required)

Yes

How many?(Required)

Is the home fully sprinklered?(Required)

Yes

Is there a basement?(Required)

Yes

Finished or unfinished?(Required)

Finished

Unfinished

Is there an active centrally monitored alarm system for both fire and theft?(Required)

Yes

Does the property have a flow-based water leak detection system tied into the central alarm system with automatic water shutoff?(Required)

Yes

Does the property have low-temperature monitoring tied into the central alarm system with automatic water shutoff?(Required)

Yes

Is there a fire hydrant within 1,000 feet?(Required)

Yes

Unknown

If there IS NOT a fire hydrant within 1,000 feet of the home, what large alternative sources of water are accessible either on or near the Property in the event of a fire? Check all that apply:(Required)

Dry Hydrant

In-Ground Pool

Pond, Lake or Stream

They are on or near the Property (within 500 feet)?(Required)

On Property

Near Property

Distance to the main/other permanent structures?(Required)

0-100 Feet

100-250 Feet

250-500 Feet

Over 500 Feet

Is there a fire station within 5 miles?(Required)

Yes

Unknown

Name of and Contact Information for the closest responding Fire Department:(Required)

Approximate Distance to the home:(Required)

FORMATTED in tenths of a mile (e.g., 5.6 miles)

Travel time from the nearest fire station to the home?(Required)

Number of fire trucks at the nearest responding Fire Department:(Required)

Any Fire Trucks contain built-in water tanks?(Required)

Yes

What is the cubic capacity of each water tank?(Required)

Do you require Primary Flood Insurance?(Required)

Yes

Any canine residents in the household?(Required)

Yes

Please provide total number along with breed and bite history of each:(Required)

Current flood zone:(Required)

Do you have an Elevation Certificate (EC) completed within the past 12 months?

Yes

What is the home’s current positive elevation for flood?(Required)

Formatted in tenths of feet (e.g., 8.3 feet)

Do you intend to move-in / live-in the Property within 30 days of closing?(Required)

Yes

Please describe:(Required)

Are any renovations planned immediately after closing/policy issuance?(Required)

Yes

Please describe:(Required)

Do you have a permanently-installed, bolted-down safe?(Required)

Yes

PROPERTY INFORMATION - California / Seismic / Brush

Address for which you need insurance:(Required)

Address Line 1 Address Line 2 City State Zipcode

Is the mailing/billing address the same as the property address to be insured?(Required)

Yes

Mailing/billing address:(Required)

Address Line 1 Address Line 2 City State Zipcode

Type of Construction:(Required)

Year Built:(Required)

Number of Stories:(Required)

Foundation Type:(Required)

Is the Home built to current Earthquake code or retrofitted for Earthquake?(Required)

Yes

PROPERTY IS INELIGIBLE FOR COVERAGE

Is the Home built to current Earthquake Code or retrofitted for Earthquake(Required)

Built to Current Earthquake Code

Retrofitted for Earthquake

Retrofitted in which year?(Required)

Any prior structural damage due to Earthquake/Temblors/Seismic Activity?(Required)

Yes

Please describe:(Required)

Date of Loss – Drop Down Menu MM YYYY – Description Free Form 3 lines – Outcome – Approved or Declined – Settlement Amount – Formatted to Dollar Value $XXX,XXX

Does the Home have a Seismic Shut-Off Valve?(Required)

Yes

Is the shut-off tied into the home’s central alarm system?(Required)

Yes

Distance to closest Brush?(Required)

Any prior brushfire damage to the Home or the surrounding properties in the general proximity?(Required)

Yes

Please describe:(Required)

Has the entire home been sprayed within the past year with a flame retardant?(Required)

Yes

Please provide the estimated date:(Required)

Type of Heat:(Required)

Oil

Natural Gas

Electric

Where is the Tank?(Required)

Is Oil Tank under an active maintenance contract?(Required)

Yes

Year of the last complete updates to the plumbing, electrical, roof & heating:

Plumbing:(Required)

Electrical:(Required)

Roof:(Required)

Heat:(Required)

Roof Shape:(Required)

Roof Covering Type:(Required)

How is the roof attached to the structure?(Required)

Is there a roof deck?(Required)

Yes

How is it attached to the structure and roof?(Required)

Is the roof and gutters under an active maintenance contract?(Required)

Yes

Door and window protection:(Required)

Any working wood fireplaces/chimneys?(Required)

Yes

How many?(Required)

Are the fireplaces and chimneys under an active maintenance contact?(Required)

Yes

Any propane stoves?(Required)

Yes

How many?(Required)

Is the home fully sprinklered?(Required)

Yes

Is there a basement?(Required)

Yes

Finished or unfinished?(Required)

Finished

Partially Finished

Unfinished

Is there an active centrally monitored alarm system for both fire and theft?(Required)

Yes

Does the property have a flow-based water leak detection system tied into the central alarm system with automatic water shutoff?(Required)

Yes

Does the property have low-temperature monitoring tied into the central alarm system with automatic water shutoff?(Required)

Yes

Does the alarm system contain backup signal continuity?(Required)

Yes

Does the Property have a full-house backup generator?(Required)

Yes

Are the primary structures equipped with lightning protection?(Required)

Yes

Does the Property contain an in-ground pool?(Required)

Yes

Is the pool completely fenced?(Required)

Yes

Is the pool equipment protected from the elements?(Required)

Yes

Is the property perimeter totally fenced?(Required)

Yes

Is there a fire hydrant within 1,000 feet?(Required)

Yes

Unknown

If there IS NOT a fire hydrant within 1,000 feet of the home, what large, alternative sources of water are accessible either on or near the property in the event of a fire? Check all that apply:(Required)

Dry Hydrant

In-Ground Pool

Pond, Lake or Stream

They are on or near the property (within 500 feet)?(Required)

On Property

Near Property

Distance to the main/other permanent structures?(Required)

0-100 Feet

100-250 Feet

250-500 Feet

Over 500 Feet

Is there a fire station within 5 miles?(Required)

Yes

Unknown

Name and contact information for the closest responding Fire Department:(Required)

Approximate distance to the home?(Required)

FORMATTED in tenths of a mile (e.g., 5.6 miles)

Travel time from the nearest fire station to the home?(Required)

Number of Fire Trucks at the nearest responding Fire Department:(Required)

Any Fire Trucks contain built-in water tanks?(Required)

Yes

What is the cubic capacity of each water tank?(Required)

Any canine residents in the household?(Required)

Yes

Please provide total number along with breed and bite history of each:(Required)

Do you require Primary Flood Insurance?(Required)

Yes

Current flood zone:(Required)

Do you have an Elevation Certificate (EC) completed within the past 12 months?

Yes

What is the home’s current positive elevation for flood?(Required)

Formatted in tenths of feet (e.g., 8.3 feet)

Do you intend to move-in/live-in the property within 30 days of closing / policy issuance??(Required)

Yes

Please describe:(Required)

Are any renovations planned immediately after closing / policy issuance?(Required)

Yes

Please describe:(Required)

Do you have a permanently-installed, bolted-down safe?(Required)

Yes

PROPERTY INFORMATION - Rural Coastal Free-Standing Home

Address for which you need insurance:(Required)

Address Line 1 Address Line 2 City State Zipcode

Is the mailing/billing address the same as the property address to be insured?(Required)

Yes

Mailing/billing address:(Required)

Address Line 1 Address Line 2 City State Zipcode

Type of Construction:(Required)

Year Built:(Required)

Number of Stories:(Required)

Foundation Type:(Required)

Type of Heat:(Required)

Oil

Natural Gas

Electric

Where is the Tank?(Required)

Is Oil Tank under an active maintenance contract?(Required)

Yes

Year of the last complete updates to the plumbing, electrical, roof & heating:

Plumbing:(Required)

Electrical:(Required)

Roof:(Required)

Heat:(Required)

Roof Shape:(Required)

Roof Covering Type:(Required)

How is the roof attached to the structure?(Required)

Is there a roof deck?(Required)

Yes

How is it attached to the structure and roof?(Required)

Are the roof and gutters under an active maintenance contract?(Required)

Yes

Door and window protection:(Required)

Any working wood fireplaces/chimneys?(Required)

Yes

How many?(Required)

Are the fireplaces and chimneys under an active maintenance contact?(Required)

Yes

Any propane stoves?(Required)

Yes

How many?(Required)

Is there a basement?(Required)

Yes

Finished or unfinished?(Required)

Finished

Partially Finished

Unfinished

Is there an active centrally monitored alarm system for both fire and theft?(Required)

Yes

Does the property have a flow-based water leak detection system tied into the central alarm system with automatic water shutoff?(Required)

Yes

Does the property have low-temperature monitoring tied into the central alarm system with automatic water shutoff?(Required)

Yes

Does the alarm system contain backup signal continuity?(Required)

Yes

Does the Property have a full-house backup generator?(Required)

Yes

Are the primary structures equipped with lightning protection?(Required)

Yes

Does the Property contain an in-ground pool?(Required)

Yes

Is the pool completely fenced?(Required)

Yes

Is the pool equipment protected from the elements?(Required)

Yes

Is the property perimeter totally fenced?(Required)

Yes

Is there a fire hydrant within 1,000 feet?(Required)

Yes

Unknown

Dry Hydrant

In-Ground Pool

Pond, Lake or Stream

They are on or near the property (within 500 feet)?(Required)

On Property

Near Property

Distance to the main/other permanent structures?(Required)

0-100 Feet

100-250 Feet

250-500 Feet

Over 500 Feet

Is there a fire station within 5 miles?(Required)

Yes

Unknown

Name and contact information for the closest responding Fire Department:(Required)

Approximate distance to the home?(Required)

FORMATTED in tenths of a mile (e.g., 5.6 miles)

Travel time from the nearest fire station to the home?(Required)

Number of Fire Trucks at the nearest responding Fire Department:(Required)

Any Fire Trucks contain built-in water tanks?(Required)

Yes

What is the cubic capacity of each water tank?(Required)

Any canine residents in the household?(Required)

Yes

Please provide total number along with breed and bite history of each:(Required)

Do you require Primary Flood Insurance?(Required)

Yes

Current flood zone:(Required)

Do you have an Elevation Certificate (EC) completed within the past 12 months?

Yes

What is the home’s current positive elevation for flood?(Required)

Formatted in tenths of feet (e.g., 8.3 feet)

Do you intend to move-in/live-in the property within 30 days of closing / policy issuance?(Required)

Yes

Please describe:(Required)

Are any renovations planned immediately after closing / policy issuance?(Required)

Yes

Please describe:(Required)

Do you have a permanently-installed, bolted-down safe?(Required)

Yes

COVERAGE INFORMATION

Estimated aggregate value of your ‘everyday’ ‘1st-year’ personal contents:(Required)

Includes Furniture, Home Furnishings, Electronics, Clothing, Shoes, Ladies/Mens Accessories, Luggage, Supplies for the Kitchen/Bedrooms/Baths, Personal Items/Effects, etc.

What Personal Liability limit would you like?(Required)

It is recommended that Policyholders should carry sufficient liability protection to shield their net worth from personal lawsuits involving eligible claims of Bodily Injury, Property Damage & Personal Injury (libel, slander, defamation, etc.)

What base deductible would you like?(Required)

Some carriers do not offer a $500 deductible for either Homeowners or Renters properties.

VALUABLE ARTICLES COLLECTIONS (VAC)

Will you be insuring any of your Valuable Articles Collections (VAC) in the following categories: Jewelry/Watches, Fine Art, Wine, Silver, Musical Instruments, Cameras, Sports Memorabilia, Coins/Stamps, Furs, Porcelain/Figurines/Other Collectibles(Required)

Yes

Valuable Articles Collections (VAC) – Estimated Total Value of Each Valuable Articles Category to be Insured

Jewelry / Watches:

Fine Art:

Includes Paintings, Sculpture, Photography, Illustrations, Sketching, Antique Furniture, Persian Rugs, etc.

Wine:

Silver:

Musical Instruments - Hobby:

Cameras - Hobby:

Sports Memorabilia:

Coins / Stamps:

Furs:

Porcelain / figurines / Other Collectibles and Sets:

Valuable Articles Only Addons

Do you own or rent your primary residence?(Required)

Own

Rent

Property Type:(Required)

24-Hour Security(Required)

Yes

Cameras in the Elevators(Required)

Yes

Is there a central alarm for both fire and theft?(Required)

Yes

Do you have a permanently-installed, bolted-down safe?(Required)

Yes

MOTOR VEHICLE

Would you also like a Motor Vehicle quote?(Required)

Combining Your Home & Auto Coverage Can Potentially Save Up To 10% Per Year

Yes

Motor Vehicle Property Information

Address:(Required)

Address Line 1 Address line 2 City State Zip Code

Do you have a separate garaging address?

Yes

Garaging Address:(Required)

Street Address Address Line 2 (Optional) City State ZIP Code

Is the mailing/billing address the same as above?(Required)

Yes

Mailing/billing address:(Required)

Street Address Address Line 2 (Optional) City State ZIP Code

Motor Vehicle Information

Add an entry for each motor vehicle below to be insured:

Motor Vehicle Type	Year	Make	Actions

There are no Entries.

Maximum number of entries reached.

Do you currently have Motor Vehicle insurance in-force?(Required)

Yes

Is this the first time insuring a Motor Vehicle or has it been more than 30 days since the last time you had active motor vehicle insurance?(Required)

First Time

More Than 30 Days

Current Motor Vehicle Coverage Information

Current auto insurance carrier:

Number of years insured by your current carrier(Required)

1-5

Current bodily injury liability limit(Required)

State Minimums

100/300K

Less than 30K Combined Single Limit (CSL)

300K CSL or Higher

Please upload your current Declaration Page/Coverage Summary from the current Motor Vehicle Insurance Polic(ies):

Drop files here or

Max. file size: 256 MB.

Accepted file types: doc, docx, xls, xlsx, csv, ppt, txt, pdf, jpg, gif, png, heic, Max. file size: 10 MB. Suggested formats: Word, Excel, PowerPoint, PDF, JPG, GIF, PNG

Requested Motor Vehicle Coverage

Requested Bodily Injury & Property Damage Limits:(Required)

Combined single limit (CSL) $300K

CSL $500K

CSL $1,000,000

Split limit: $100K / $300K / $100K

Split limit: $250K / $500K / $100K

Requested deductibles for collision and comprehensive (other than collision) - Both with full window glass:(Required)

$1,000

$2,500

$5,000

$500

Greater Than $5,000

Would you like roadside service coverage?(Required)

Yes

Ownership Information - Lienholder /Loss Payee / Additional Interest Information

Is the Motor Vehicle to be insured:(Required)

Loss payee name:(Required)

Address:(Required)

Address Line 1 Address Line 2 City State Zip Code

Financed - Lienholder / Additional Interest Name:(Required)

Address(Required)

Address Line 1 Address Line 2 City State Zip Code

Motor Vehicle Insurance Related Losses / Claims

Any losses/claims/accidents/violations in past 5 years?(Required)

Claim Details:

Loss Date	Description	Settlement Amount	Is claim closed or open?	Actions

There are no Entries.

Maximum number of entries reached.

How long were you insured with that claims carrier?(Required)

What were injury body limits they carried at that time?(Required)

UMBRELLA / EXCESS LIABILITY

Umbrella/Excess Liability Coverage Limit Requested?(Required)

How Many Drivers In Household?

Drivers License Number:	State of Issuance:	Expiration Date:	Actions

There are no Entries.

Maximum number of entries reached.

Enter all Properties to be Insured Under the Umbrella / Excess Liability:

Address	Actions

There are no Entries.

Maximum number of entries reached.

Enter all Motor Vehicles to be Insured Under the Umbrella / Excess Liability:

Motor Vehicle Type	Year:	Make:	Actions

There are no Entries.

Maximum number of entries reached.

Any Umbrella / Excess Liability Claims Within the Past 5 Year?(Required)

Yes

Please Describe:(Required)

WATERCRAFT

Enter all Watercraft(s) to be Insured Below:

Type of Watercraft	Year:	Manufacturer:	Actions

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Liability Limits:(Required)

Physical Damage Deductible(Required)

$100 - Value $50,000 or Less

$250 - Value $50,000 or Less

$500 - Value $50,000 or Less

$1,000 - Value $50,000 or Less

1% - Value $50,000 or Greater

2% - Value $50,000 or Greater

3% - Value $50,000 or Greater

Loss History for Past 3 Years:(Required)

Yes

Please Describe:(Required)

Loss Payee Name:(Required)

Loss Payee Address(Required)

Address Line 1 Address Line 2 City State ZIP Code

Loan Number:

Boating Experience Total Years:(Required)

What Type of Boat(s) Have You Driven?(Required)

How Many Drivers will have Access to the Boat?(Required)

Driver's License Number:(Required)

State of Issuance:(Required)

Expiration Date:(Required)

Do You Have a Clean Motor Vehicle Record?(Required)

Yes

Please describe:(Required)

PRIMARY / EXCESS FLOOD

Property address for which you need insurance:(Required)

Street Address Address Line 2 City State ZIP Code

Property Type:(Required)

Free-Standing Type:(Required)

Standard

Rural Coastal

California Seismic Brush

Any Prior Flood Losses?(Required)

Yes

Please describe each loss within the past 5 years:(Required)

Year Built:(Required)

Construction Type:(Required)

Residency Type:(Required)

Foundation Type:(Required)

Number of Stories:(Required)

Any Other Permanent Detached Structures on Property?(Required)

Yes

Structure Types:(Required)

Detached Garages

Pool House

Shed

Other

Is There an In-Ground Pool?(Required)

Yes

LIFE / DISABILITY / LONG-TERM CARE

Objectives for Securing Life / Disability Insurance:(Required)

Coverages:(Required)

Term Life

Whole Life

Long Term Disability

Term Life Length(Required)

10 Year

20 Year

30 Year

40 Year

Hospital Coverage(Required)

With Coverage

Without Coverage

What coverage amount would you like?(Required)

Any Chronic or Current Health Conditions?(Required)

Yes

Please list any chronic medical conditions or diseases (e.g., diabetes, heart disease, cancer, etc.):(Required)

Do You Take any Medications Regularly?(Required)

Yes

Please list any medications you take regularly/(Required)

Please include the prescription name, dosage, and frequency per day.

Does cancer, diabetes, high-blood-pressure, high cholesterol, heart disease or other chronic condition run in your family of origin?(Required)

Yes

Do you drink alcohol or smoke marijuana?

Yes

Please include frequency amount estimate:(Required)

Have you ever been diagnosed and treated for depression, anxiety, addiction or another medically-diagnosed condition?(Required)

Yes

Are your parents alive?(Required)

Yes

Please list their ages and any chronic medical conditions they experience:(Required)

Please indicate when they passed and the cause of death:(Required)

Important Medical Examination Disclosures

• As part of the underwriting process for many forms of Life Insurance, including Permanent (Whole) Life, a medical examination may be required.

• The exam is intended to verify the current state of each applicant’s overall physical health as indicated on the client’s application for insurance.

• The medical examination will be conducted by a physician chosen by the insurance company and can be held at your preferred location, including either your office or your home. The entire exam usually lasts no more than 10-15 minutes.

• As part of the medical examination, the applicant will be required to submit a fresh urine sample as well as allowing blood to be drawn.

• Any information provided by the applicant during the entire underwriting process for insurance, including but not limited to (a) answers to the questions included in this worksheet; (b) results of your physical examination; (c) follow-up/additional information requested by the insurance carrier’s underwriting team; etc., will be kept private & strictly confidential in compliance with national HIPAA requirements.

• All information provided by the applicant will be considered part of the underwriting process and may impact the carrier’s final offering/premium for binding – which may be higher or lower than the initial premiums quoted. The insurance carrier always retains the sole/final authority on all underwriting/pricing/claims decisions associated with a life insurance application/policy.

• At the completion of the application/quoting/sales process, if an applicant decides not to purchase a policy or if the applicant is declined for coverage by the insurance carrier for medical reasons or for any other reason, the carrier & its representatives will strictly adhere to all HIPAA requirements to provide the utmost, ongoing protection for the all of the applicant’s personal and private information provided.

SPECIALTY INSURANCE

MORTGAGEE / ADDITIONAL INTEREST INFORMATION

Is/Will there be a mortgage?(Required)

Yes

First mortgagee bank/lender name:(Required)

Loan Number:(Required)

Mortgagee Clause/Bank Address:(Required)

Address Line 1 Address Line 2 City State ZIP Code

Mortgage banker name:(Required)

Mortgage banker phone:(Required)

Mortgage banker email address:(Required)

Enter Email Confirm Email

Fax #:

Is there a second mortgage?(Required)

Yes

Secondary mortgage bank/lender name:(Required)

Loan Number:(Required)

Secondary Mortgagee Clause/Bank Address:(Required)

Street Address Address Line 2 City State ZIP Code

Secondary Mortgage banker name:(Required)

Secondary Mortgage banker email address:(Required)

Enter Email Confirm Email

Secondary Mortgage banker phone number:(Required)

Fax #:

Any other additional interest?(Required)

Yes

Homeowners association, property manager, etc.

Additional Interests

Additional Interest Type	Additional Interest Contact Name:	Actions

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ADDITIONAL INTEREST INFORMATION - Renters/Tenents

Any other additional interest?(Required)

Yes

Homeowners association, property manager, etc.

Add Additional Interests:

Additional Interest Type	Additional Interest Contact Name:	Actions

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CLAIMS INFORMATION

Within the past 5 years, have you experienced any insurance losses or claims?(Required)

Yes

Please provide a brief description of each loss occurrence, including the approximate date outcome and payout:

Be sure to include the loss date (estimate) and the loss amount (estimate)

OTHER INFORMATION

Please feel free to attach other relevant information you’d like us to consider as part of your submission. Examples include: Mortgagee Bank Insurance Requirements, Lease Insurance Requirements, Elevation Certificates, Property Appraisals/Inspection Reports, Seller’s Current Insurance Policy, etc. You may upload a total of 10 MB in the following approved formats: Word, Excel, PowerPoint, Google Sheets, PDFs, Image Files, or Text Files

Additional comments/input:

Please feel free to provide other pertinent details

Upload supporting documents:

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Max. file size: 10 MB.

Phone

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